By Evan Falchuk

At the Health Affairs Blog, Dr. Caroline Poplin writes a thoughtful and contrarian view of the concept of the  “medical home.”

Buried in the article is a scathing critque of the conventional wisdom around quality measures and quality improvement:

If pay for performance is the solution, then the quality problem must be due to primary care physicians who are lazy and ignorant, indifferent to the welfare of their patients and unaware that time and scientific progress have passed them by.  Why else would they fail to give beta blockers to patients who suffered heart attacks?. . . . Every physician wants to render the best care for her patients that she can.  There is no reason to think that if a physician has ready access to the right information at the right time, and is given enough time and paid adequately for their efforts, she will do the wrong thing.

She’s right, of course.  And studies that show that nearly 60% of office visits feature face-to-face contact with a doctor of less than 15 minutes suggest that we’re starving doctors of the time they need to do this.  But she also suggests that the medical home may be the same old managed care, repackaged:

The attitude that physicians who practice clinical medicine must be supervised and held accountable by physicians who don’t is troubling . . . To them, the patient-centered medical home looks more like a Skinner box:  endless requirements imposed by distant “experts” in the name of quality and efficiency, more suited to the assembly line than to the practice of a profession.  A true professional will welcome — indeed seek out — real help.  He should not need detailed guidance.

Dr. Poplin’s frustration reflects things I have heard doctors tell me all across the country.  For whatever else managed care has accomplished, it has been successful in alienating doctors.  It’s too bad, because there are a number of well-intentioned efforts out there, and doctors — especially those who practice clinical medicine — need to be in the vanguard.

If the problem is that current approaches to quality are disconnected from the reality of the practice of medicine, doctors must drive that message “home.”