Not that it's mature yet by any means, but the concept of the medical home is well out of the primary care nursery – out in the big wide world, where who knows what might befall it. It is constrained by NCQA rules, liable to be mugged by referral specialties who are after some of the money it's supposed to carry, and exposed to any number of community-acquired diseases.

It recently caught a slight case of the managed care pox from a Boston Globe article (“‘Medical home’ approach brings back managed care,” April 8, 2009; see http://tinyurl.com/ce5uvd). It already has a touch of diabetes acquired from various “Diabetes Medical Home” pilot programs, and it's at risk for other chronic diseases. Disagreement over its definition and components may lead to personality disorder. Worse, it's developing symptoms of congressional politics – and you know where that can lead.

This could be serious trouble. Aside from risks that the concept will be co-opted, misconstrued or distorted and aside from the difficulty of do-it-yourself medical home construction, the main problem is how the twin attractions of the medical home fare. Like the beer with the competing claims, “Less filling!” and “Tastes great!” the medical home promises less expensive care that is also better care. In a society that values quality, the medical home will be where everyone wants to live. In a society that values money, it will be where those with the money want everyone to live.

The difference can be enormous. Whatever else it does, the medical home is supposed to give curb appeal to primary care, which, for all its demonstrated virtues, hasn't been selling well of late, particularly to medical students and payers. If payers and the government eventually embrace the medical home concept but then start forcing patients to move in … Well, do you remember managed care? The apparently mistaken assessment of the Globe article may turn out to be prophetic.

The medical home was raised to be a charming, rose-covered cottage with high-speed Internet and all the modern conveniences. If it isn't careful, some day soon it may have all the allure of a half-way house. Like proud parents of a promising child, proponents of the medical home can only pray that it will survive the Dickensian vicissitudes of the real world and emerge relatively unscathed.