While our colleague Paul Testa was going through the latest numbers on the incredibly shrinking primary care work force, we were over at the Health Affairs session listening to Robert Berenson of the Urban Institute talk about how to build the Medical Home, which is in some ways a souped up 21st century version of primary care.

Bob (who has guest blogged for us in the past) said a lot of docs don't like primary care in our current world because of what he called the hamster syndrome. They feel like they are hamsters spinning on wheels in a cage, unable to keep up, unable to move ahead. The medical home is supposed to restore primary care's rightful place in the healthcare universe, while as Berenson wrote in the current issue of Health Affairs, "providing a source of confidence, advocacy, and coordination for patients as they encounter the disconnected parts and often daunting complexity of the health care system." Advocates of medical homes stress their importance in managing chronic diseases. Naturally, to make them work, we're going to have to pay primary care providers better and differently if we want care coordination and oversight to replace piecemeal, pay-for-procedure medicine.

Berenson likes the idea of medical homes (as do we here at New America). But he's worried that the buzz could get ahead of the reality. People don't agree on exactly what a medical home is, or should be, what it can achieve versus what it can be expected to achieve. Without some broader consensus on what medical home means, and who it should serve (everybody or the chronically ill?) Berenson fears, "it would not be the first time that a good health policy idea was judged a failure because of premature promotion."

He also worries that medical homes could be too rigidly defined. A solo practitioner could constitute a medical home, as could a team of doctors, or a small group of doctors working with a larger group of nurse-practitioners, or a large multispecialty group of doctors that coordinate and integrate care for patients with such conditions as diabetes, asthma and congestive heart failure. Most definitions of medical homes require that they have electronic medical records, and many include alternatives to face-to-face office visits, including email. Berenson wants change, but he wants smart change.

"Many practices, including some that appear to do a conscientious job of providing patient-centered primary care, will feel threatened by a medical home model that immediately disrupts the basic orientation of their practices and implicitly threatens their professional self-esteem." In other words, the challenge is change that can get doctors off that hamster wheel instead of making them feel like they are just spinning faster.