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Letters - Learning What Patient-Centered Medical Home Really Is
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In the ninth year of our medical home journey, it has become clear that PC-MH is not solely a technology, although there are technological capabilities which support medical home; it is not solely a methodology, although there are reproducible methods which sustain medical home and it is not simply a structural transformation within a healthcare organization.  In reality, genuine medical home is a product and a process birthed of a shared personal vision, passion and commitment, evident before an organizational commitment to pursue PC-MH, present during a formal healthcare encounter, and operable in all inter-personal encounters every day.

I did not learn this at a seminar, during a webinar or from a power-point presentation.  I learned it by a seemingly chance encounter while on vacation in August of 2016.

In 1962, I was a sophomore in college.  I had an on-campus job but had very little money.  What I made was sent directly to my mother and father for helping with my tuition and other expenses.  I was eighteen years old when I met a young man who had just started college.  He never smiled and I wondered why.  Watching him talk one day, I realized that his teeth were severely decayed and he was self-conscious.  Because I had watched my parents, who were not wealthy, help others all of my life, I wondered what I could do.  I consulted a dentist and asked what it would cost to restore this young man’s teeth.  Fifty-five years ago, that meant a total mouth extraction and dentures. 

When he told me the cost, I asked if he would do the work and allow me to pay him the following summer when I would have a job.  He agreed.  Another student agreed to share the cost and the work was done.  The transformation in this young man went far beyond his physical appearance.  The next summer, I paid my half and returned to school only to discover that the other half had not been paid and was not going to be.  Rather than complain, I took the money which I had for meals – the university meal plan did not start for two weeks – and paid the debt. 

The power of that experience has lasted a life time such that in August, 2016, when my wife and I were on vacation, that 1962 experience resurfaced.  As we checked into a motel, we met a young lady who was very pleasant.  After having a meal and settling into our room, I went back to the lobby.  I found the young lady and said to her, “Will you do me a favor?”  She agreed and I asked her to smile.  She did and my observation was confirmed, her teeth were totally rotten and grotesquely decayed.

I said to her, “Have you every wanted to have your teeth fixed?”  She said that she had and I added, “But, you couldn’t afford it, could you?”  She said, no.  I handed her my card and said, “If you choose to contact me, I will see to it that you get your teeth fixed properly.”

The next day, while Carolyn and I were still on vacation, I received an e-mail from this young lady, it said, “Is this one of those things which is too good to be true?”  I said that it was not.  Because she lives in a very small town which is far away, the logistics of doing this “right” took eight months.  But, as of this week, her implants are completed and her smile is bright and beautiful.  Her life has changed forever.

Already, you are wondering what these stories have to do with medical home.  Let me continue.  I started practicing medicine in Beaumont, Texas in 1975.  In 1995, with three other physicians, I formed a group medical practice.  In 1997, we adopted electronic medical records (EMR) as a method of practicing and in 1999, defined ten principles for EMR and for practice development.  In 2009, we discovered that those principles were the same as the standards of patient-centered medical home.  In 2008, SETMA’s partners launched a Foundation through which our patients could be helped with obtaining the healthcare which they could not afford themselves.  Often, even those with good insurance could not afford the co-pays to see other physicians and often they needed important healthcare for which no insurance would pay.

In 2009, one of SETMA’s partners referred a patient to the Foundation for financial assistance with dental care.  The cost of that care, done correctly, was determined to be $10,400.  We asked the dentist if he would make a $4,000 contribution to the Foundation which he did and the Foundation paid him $10,400 to restore this patient’s oral health. 

In the previous three years, this patient had been in the hospital seven times.  Her health was deteriorating and her diabetes could not be controlled even on nine medications.  To show the power of oral health, after her teeth were “fixed,” in the subsequent eight years, she has not been back in the hospital; she is on one medication, her diabetes is not only under control but she has reverted to a pre-diabetes condition. 

There is no doubt in my mind that this lady’s care represents the ideal of patient-centered medical home.  What was not obvious to me until this week is that my education for PC-MH did not start in school or in a seminar, it started in a dormitory room fifty-five years ago, as an 18-year-old sophomore, who had no money but who saw a need.  And, what was not obvious to me until eight months ago is that the dynamic, the genius and the “soul” of PC-MH was active in that motel lobby, eight months ago in a small west Texas town, in a “chance” encounter with a young lady who had a need and with a couple who had the heart to care about a stranger.  In reality, at some level, almost every patient seen in a medical practice is a stranger which means that this principle is central to the healthcare experience in the medical home.

What Have We Learned?

Economically, the medical-home exchange of 1962 cost 1/63rd of the one in August, 2016.  The principle is that the worth of a gift is not judged by its dollar value, but by what it costs you.  In reality, the 1962 gift was more expensive to me than the 2016 gift.  We learned that the discipline of giving and the inclination to embrace an opportunity for giving can be learned.  The heart for giving is a gift itself, but the practice of giving perpetuates itself across many different life experiences.  All three experiences example Winston Churchill’s dictum:  You make a living by what you get; you make a life by what you give.”

Medical home is not something we practice only in a structured-healthcare encounter.  Medical home is a dynamic of one’s life which is active within every human interaction.  The preparation for 2009 and 2016 began in 1962.  The spirit of PC-MH blossomed in 2009 but the seed was planted in 1962.  It is not possible to anticipate when the next bloom will appear, but the certainty of its appearance is absolute.

No doubt medical home has a technology and a methodology, but no doubt it is not a technology or methodology.  No doubt that medical home can be measured but more certainly it will be observed.  And, as for “oral health in the health home,” the lesson to learn is that the global health impact of medical home cannot be achieved without the constituent disciplines of dental care, mental health, emotional health and even spiritual health.

Experience and observation prove to us that public health policy would be advanced by the inclusion of comprehensive dental health in a payment plan.  The cost savings of current and future healthcare for the three people discussed above will the in the tens of thousands of dollars.  The benefit to their quality of life is immeasurable.

For the medical home to participate in finding comprehensive dental health for patients is both a choice and an opportunity.  SETMA was fortunate for a number of years to be able to invest $500,000 a year into the SETMA Foundation and thereby into the lives of our patients.  With the pressures of the Affordable Care Act and the Federal reductions in the funding of Medical Advantage, we can no longer do that.  However, our choices allow us to continue to support the participants in SETMA’s medical home with resources redirected to the care of those we care for and for whom we care about.


SETMA I
2929 Calder
SETMA II
3570 College
Mark A. Wilson Clinic
2010 Dowlen
Nederland
2400 Highway 365
Orange
610 Strickland Drive
Lumberton
137 N LHS Drive

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