I’m in correspondence regarding the concept of Advanced Primary Care with someone from a rather large corporation who feel that the senior executives are having trouble distinguishing or telling the difference between a medical home and a the old HMO concept of primary doc being the gatekeeper in terms of who picks the specialists and asked id I can you help explain the difference.

It strikes me that the difference is both one of attitude and a new emphasis on evidence based care. From the standpoint of the HMO, the insurance company dictated the “panel” based on who would accept their fee schedule and paid PCPs not to refer. The “advanced primary care model”, depending on how it’s set up, allows the patient to go see anyone (no reward for denying service) with several caveats. 1) The specialist must provide outcomes to the primary care office. Meaning, if you are seeing the specialist for a blocked carotid artery, the Primary Care doc should have a list of who does good work, bad work, or “kills people” work and you get to pick. 2) The patient must be willing to work within the “advanced primary care model” to accomplish outcomes. It turns out that it isn’t about one doctor but it’s that the patient is seeing several doctors who’s area of expertise overlap. All of the data needs to go to the “advanced primary care” practice, who will share that info with all of the other doctors. Most people think that happens, anyway. If one doc is unwilling to share then that doc is not referred to but would you really want to see that person anyway? 3) Typically, a lot can be done in the primary care office. Some plans pay a differential to the specialist if they accept someone on referral vs seeing people off of the street. In that way I can catch the person who needs their lipids checked while taking their skin tag off and give them a flu shot. If they want to see the dermatologist, they can, but at a higher out-of-pocket cost

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