The patient-center medical home and managed care: times have changed, some components have not.

I am a full supporter of the patient-centered medical home as an organizational model for practice, and I am hopeful this model will provide an enduring change for better primary care. I have seen evidence that some physicians enjoy this new model but are also describing rather easily the flaws of “managed care” from the last generation of systemic payment model changes in US health care. I think we must be careful to have a more balanced understanding of “managed care” of the 1990s, just as we wish others to have a balanced approach to the patient-centered medical home. The list of attributes from one state academy (Figure 1) could have come from any state. It creates temporary comfort for us but does not necessarily provide a productive stance toward the future. To explain, I will share my perspective on the dangers of creating a slogan and “scapegoat” out of any part of this nationwide systemic struggle to improve the patient experience, improve measured health outcomes, and reduce overall costs. The older payment and practice model we called “managed care” and payment incentives that support the evolving medical home have many things in common, as well as some differences. During the 1990s, the United States had a brief period of nearly flat cost curves for health care, mostly via the application of “managed care” systems of payment for well-organized practices. During some of those years I helped lead one moderate-sized integrated primary care system under the title of “managed care” at HealthPartners in Minnesota. Others of you may have had similar roles. We did hold down costs and we improved care for many populations. This was achieved partially by restricting choices for patients and providers via a variety of methods that led to measurable improvements to care in most integrated systems. But the public was not fully informed that their health care costs were flat or declining for those 5 to 6 years partially because they were, for example, “encouraged” or forced to choose a primary care practice, use preferred drugs on a formulary, and use a defined network of specialists and hospitals linked to tightly controlled payment contracts. Physicians were left the task of explaining this without much support. Some of the improved outcomes and lowered costs also derived from patient education and prevention efforts, although that is harder to document. In my dealings with large employers during that time, I saw them grow tired of paying $1 to $2 per member per month for phone-based care support, health education, and lots of outreach to patients—all of which was not what they considered “real care,” (ie, visits). When they saw the cost curve was merely flat and not declining, they gradually withdrew their contracted financial support for these “added” services and saved several dollars per member per month. Capitated payments to providing systems, physicians, and health plans declined for most of that “nonvisit” care. Simultaneously, employers became worried about the backlash over restricted choices and disowned the job of explaining to the public and employees that they could opt for wider choices only if they paid the associated higher costs. Employees and employers could save money mostly if they agreed to more limited options. Negative feedback regarding constrained choices was felt keenly by benefits managers and executives in many administrative layers Submitted 11 April 2011; revised 31 May 2011; accepted 6 June 2011. From the Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN. Funding: none. Conflict of interest: none declared. Corresponding author: Macaran A. Baird, Department of Family Medicine and Community Health, University of Minnesota, MMC 381, 420 Delaware St. SE, Office 6 –240 PWB, Minneapolis, MN 55455 (E-mail: [email protected]).