COMMENTARY

The Simple Reason the Medical-Home Study Failed

John M. Mandrola, MD

Disclosures

March 06, 2014

Editor's Note:
This post originally appeared at drjohnm.org

This week, the Journal of the American Medical Association (JAMA) published a comprehensive study that has major health implications.[1] Major because the negative findings should change how Americans think about health and healthcare. Plus, the findings validate a belief this doctor holds as truth.

First my belief, then the study.

One blog is enough for any practicing doctor, but if I were to start another, its name would be "Health Cometh Not From Healthcare."

Nary a day goes by that I don't see an example of how good-intentioned active management of a patient causes problems. (BTW: My son, a grammar prescriptivist, says I shouldn't use that word, "nary.") Emergency rooms overflow with elderly patients who have fallen because of BP goals. Last week, I saw a patient admitted (for confusion) with dangerously low sodium levels because of high BP treatment. It's the same story with aggressive blood sugar control, statins in the elderly, and NSAIDs, and we have already discussed the limits of screening for disease. The good-intentioned-but-harmful-treatment list is a long one.

The success of managing chronic disease does not turn on doctors or nurses. It turns on the patient and his or her choices. One of the wisest doctors in my hospital once gave me unforgettable advice: he said doctors don't control outcomes.

The JAMA study:
Health policy experts believed that active management of patients with chronic disease would lead to better outcomes. The team approach is called the patient-centered medical home. Though a great idea on paper, an analysis of outcomes in this large pilot study showed no benefit on accepted measures of quality.[1] More important, medical homes did not prevent hospital admissions and ER visits. (This, despite lofty bonuses paid to the doctors -- $92,000.)

What an important lesson for everyone involved in healthcare.

For health policy people and doctors, this lesson should help redirect our efforts towards helping patients make better choices about their health. If we must measure surrogates, let's measure simpler ones, such as weight, belt size, and 5K walk time. Let's be clear-eyed about something: When we substitute pills, tests, and procedures for simple things like eating well, moving, sleeping, and smiling, we risk making our patients worse.

For patients, the lesson here is that doctors can help treat problems that develop, and we can teach you things about your body and health, but we can't make you truly healthy. A teacher can't do her student's homework, a coach can't throw the pass, and a doctor can't stop you from eating potato chips.

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