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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