Is the medical home really worth it?

Patient-centered primary care medical homes (PCMHs) are all the rage. A frequently-touted part of the Affordable Care Act (ACA), they have received literally hundreds of millions of dollars in federal incentive and demonstration-project funding. They’ve been around for decades. In fact, the more you know about the intention behind the creation of a primary care patient-centered medical home (PCMH), the more you want to ask, “Well, of course – how could that not be a good idea?”

But is it?

Creating a medical home means building and using an integrated approach to health care where each piece of care is not treated separately and does not take place in isolation — nor is it all billed separately. Health care, communication, co-ordination, complications, follow-up and payment are all part of one system led by primary care.

PCMH is often reported as having started in 1964 by pediatricians, in order to improve the kind of fragmented, episodic and uncoordinated care that special needs children received at the time. The idea was that the primary care doctor (a pediatrician) was the “home” for all health care, and that the patient’s family, and a care coordinator, were key members of a team.

While generally acknowledged to be an improvement for families then — numerous opinion and consensus/expert panel papers exist – it is surprisingly hard to find any randomized comparison data to support their efficacy. Despite this, PCMHs seem to inspire some of the most vaguely worded and glowing descriptions ever applied to a federally-funded regulatory initiative.  Check out this polished video from one of the medical home accreditation organizations. You’ll see retro-Marcus-Welby hype, followed by person after person struggling to explain exactly what a medical home is. Even the most technocratic PCMH document will often begin explaining a medical home as “not a place, but a model” of care. “It’s an ideal.” Or, “it’s a concept.”

If you step back a bit, however, this revealing set of phrases presents a large number of uncomfortable questions, especially when vast amounts of health care dollars are at stake. Such as, if you’re trying to change your primary care practice into a PCMH, how do you define a “concept of care”? Or, if you’re a funder, how exactly do you pay someone more or less money based on whether they’re following the “concept” or not?

Similarly, if “team-based care” is a huge part of the concept behind a PCMH, who will decide if a collection of people is actually a team or not? After all, an autocratic doctor (or any other uncooperative health care provider) plunked into a mandated “team” of other providers will likely remain just that — uncollaborative. And finally, when it comes to patients, does the same health care “concept” achieve the same outcomes for each unique person?

In an effort to define the undefinable, a complex number of criteria have been created. Just check out the multi-faceted array of “voluntary” PCMH certification criteria that currently exist, such as from the National Committee for Quality Assurance, the Accreditation Association for Ambulatory Health Care and The Commonwealth Fund. Which criteria is better? Easier to certify? Or more effective?

Even a cursory glance at our current definition shows that the medical home idea has become far broader and more complex than that original approach. More modern health care strategies, like managing chronic conditions through disease registries and using health information exchanges (HIEs) and electronic health records (EHRs), are now central to PCMHs. There are also clearly conflicting criteria, such as the twin goals that patients always have ready access to their assigned primary care provider (empanelment), and that patients receive their care through specified teams of non-physicians (coordination).

There’s also an assumption that PCMHs are right for every patient, even those with more minor medical problems. In general, the ability to just make your own appointment with a dermatologist or orthopedist goes away. You need to go through primary care first. Even for something as serious as a new cancer diagnosis, that care is supposed to be launched and monitored through primary care.

Additionally, a striking issue when looking over the criteria for PCMH certification is the fact that surprisingly few requirements make a clinic more “patient-centered.” Engaged leadership? Use of electronic health systems? That is what patients care about, more than anything else? If it is not proven that this criteria actually makes care more “patient center,” is the title of this initiative more about clever marketing? Afterall, who in health care wants to stand up and say they’re opposed to being “patient-centered”?

Despite these issues, PCMHs are proliferating rapidly. The Alliance for Health Reform’s 2013 book Covering Health Issues: A Sourcebook for Journalists, lists on page 53 the institutions and initiatives involved in documenting PCMH status – a dizzying number of agencies with their hand in the pot. With, as of May 2013, over 27,500 clinicians and 5,700 sites PCMH certified, certifying PCMH status is no longer a simple Do-It-Yourself process for clinics, but a booming nationwide industry.

But all this time and effort to make things “patient centered” has to be worth something, right?  Or is it just bad bureaucracy taking over another part of health care? Bad bureaucracy in health care isn’t just annoying. Estimates are that it eats up one third of our health care budget or as much money as it would take to care for all the uninsured. PCMHs stand to create more. As one example, between 2010 and 2012, New York’s state Medicaid program spent an estimated $398,947,964 taxpayer dollars (which includes a $250 million lump sum payment to hospitals and training centers) – from money designated for the health care of New York’s poorest, and often most medically fragile and disabled patients – to implement this certification bureaucracy.

Jan Gurley is an internal medicine physician who blogs at Doc Gurley.

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    Good morning Dr. Gurley. It’s another healthcare racket. Forced on the the actual participators by the non-participators who need to find a way to get up in the morning and put a suit on so they can go in to a job and get a check and pay a mortgage. Please note the loud sucking sound associated with the suit in your office. Also please note that when they are gone – they are never missed.

    • guest

      I personally have also noticed that the folks in the suits get to work 9-4, take vacation whenever they want, don’t appear to have specific deadlines to accomplish any bureaucratic tasks, so that things take forever to get done, and spend their days in meetings rather than actually doing anything. Nice work if you can get it…

      • NPPCP

        Reminds me of the documentaries where the shark is swimming and there are a few little leeches attached to it hanging on as it goes about its daily duties of feeding itself and making its shark living.

  • Anne-Marie

    I’ve always had the distinct impression that the people who designed this so-called model of care never stopped to think about how it would be experienced by actual patients.

    I’m unfortunately in the process of looking for a new doctor. I was perfectly happy with the doctor I had and would have much preferred to remain with him. But the nurse is so inept that I just can’t deal with it anymore – she never seems to know what’s going on, keeps forgetting to order labs and rx refills, leaves me hanging with unresolved questions, has been openly rude on several occasions, etc. (Before anyone asks, the answer is yes, I did register my concerns. Nothing changed.)

    The PCMH model assumes that everyone on the team is competent and well-functioning. But sometimes they’re not, and then what is the patient supposed to do? We can’t just “fire” one member of the team; it’s all or nothing, and then we’re put in the unwanted position of having to make a choice.

    On the other hand, PCMH teams that tolerate ineptitude and noncollaboration by one of their members perhaps are dysfunctional as an entire team.

  • LeoHolmMD

    The PCMH is primarily concerned with: 1) data mining, 2) maximizing disease trolling, prescribing and referrals, 3) insulating large systems from real measures that truly reduce utilization/costs.
    The reimbursement has yet to materialize. That’s why it all runs on grant money right now. Surprise, surprise. Most of the studies done are pre/post, which renders them almost completely invalid. The studies also suffer from substantial implementation bias. If you infuse a practice with grant money, technology, and extra staff…you would have to really screw things up to not do slightly better than a conventional practice. That is what the data shows. Dr. Gurley correctly notes the lack of real randomization and evidence backing up this recent management fad designed to parasitize what remains of Primary Care.

    • ninguem

      I wish I could give you ten upvotes for that post.

    • southerndoc1

      “If you infuse a practice with grant money, technology, and extra staff”
      And you tell everyone at the beginning of the study what the desired results are!

  • Dr. Drake Ramoray

    If you are a physician and are currently independent of hopspitals or mega corporations you have about 5 years to figure out a plan, retire, or convert to a direct payment model. This of course unless you want to be a cog in the corporatist healthcare machine. I am actively working both from a financial and credentialling side (nuclear medicine certification etc) to have a thyroid only and possibly direct pay model practice.
    The storm is coming whether ACO/PCMH “work” or not.

  • southerndoc1

    Part 2 of Dr. Gurley’s PCMH take-down is up on her blog, and it’s devastating.

  • buzzkillersmith

    Let me channel McCarthy here : The PCMH is a traveling carnival, a fevered dream, a trance bepopulate with chimeras having neither analogue nor precedent.

    In other words, toss a coin.

    Next case.

  • Wendy Felsenthal

    I think the focus should be ‘patient care’ or centeredness , which is sorely missing in today’s American medical model.
    When , as human being, I am forced to make and go to 10 separate specialists to find out why my leg hurts so bad , bring along all pertinent info(past lab work, MRI’s , etc.) to each and everyone of these separate appointments and explain , over and over again my whole health history ( which is extensive) , show relevant paperwork and try to explain why I am here to doctors who give me 10-15 minutes of their time; I can tell you I am not only mentally exhausted and disgusted w/ the typical system, I would pay extra for a team of specialists to be in one place as in the Mayo Clinic , or Cancer Centers of America, etc. . My time and energy affect my health too( and I (people w/ a health issue) am the reason why doctor’s exist….so I fail to see why I see doctor’s complaining about this model. If you are truly looking out for the patient’s best interest , than a patient centered model would be what you should strive for…it may change its look over time as it gets experimented with, but patient centeredness should be the basic goal….I would think(?) This is from a patient’s perspective who also is an advocate for residents and patients and is fairly familiar w/ the medical field .

  • MacArthur Obgyn

    Very interesting and information article. Thanks for taking the time to write this.

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