Give the medical home more time before declaring it a failure

During an afternoon seminar on a new paradigm for lung cancer screening in primary care, my phone chirped announcing the latest MedPage Today bit of breaking news: “Medical Homes May Not Be the Answer.”

A study in JAMA reported that cost per month per patient had actually increased, and only one marker of improved care was found to have improved after thousands of patients were followed in a large group of patient-centered medical home pilot projects over several years.

As far as I can tell, this should only make us want to try harder, to figure out new and improved ways to get this right. No one thought that simply creating another database, workbench, tracking tool, care coordinator specialist, would suddenly, dramatically transform us into the lean, mean, patient-centered medical home fighting machine we want to be.

As the gist of this column over the past year has demonstrated (if nothing else), getting this right is hard. Getting buy-in from all the players. Getting IT on board. Creating EHR tools. Recreating and retraining staff members. Changing long-held work patterns. Hiring and training care coordinators. Accessing community resources.

Much of the effort of the first years of implementation of a patient-centered medical home clearly go into the build, the efforts to achieve NCQA certification, and some stumbling around trying to discover what works for you, your practice, your patients, and your community.

When Dr. Semmelweis first found that washing your hands decreased the rates of puerperal fever in their obstetrical practice, he did not do a cost-benefit analysis. Most people did not believe he was onto anything. And in the more than 150 years since then we have gone on to improve sanitary conditions in healthcare up to the ultrasterilized operating rooms where not a single microbe can survive.

Does this cost more than just washing your hands? Absolutely.

Does this ultimately save money, save lives, improve outcomes? Absolutely.

We have no randomized controlled trials of appendectomy versus placebo surgery, and yet we continue to take out appendices.

The idea of a patient-centered medical home is not just to become annoying nudges to our patients, or to our providers, or to the other members of the healthcare team.

The whole purpose is to reawaken and reinvigorate, streamline and maximize, the entire healthcare experience. To truly be transformational we have to try these things out, to experiment, to let it go where it will for a while, in the hopes that we will organically proceed to a brave new world.

As we piloted one of our research protocols, looking at pre-screening patients with diabetes coming to the practice to see who needed a point-of-care hemoglobin A1c done prior to their visit, we discovered when we looked back at the first week that our new care coordinator had not realized that the prerequisite for enrollment in this protocol was actually having diabetes mellitus.

Lo and behold, the list of patients who came up as not having had a hemoglobin A1c in the previous 6 months included some patients who obviously did not have one in the last 6 months because they did not have diabetes.

The resident reviewing this protocol had missed this essential inclusion criterion, but no harm was done, a little extra effort was expended, and one patient who did not have diabetes had a hemoglobin A1c checked. (And it was normal!)

I don’t think anybody’s hemoglobin A1c is going to go down simply because they got added to a registry, or they got a post-visit call, or that someone is helping them find resources in the community to help them eat healthier and get some more exercise.

Yet.

This is clearly going to take time, it is an evolutionary process, as we transform the patient care experience and return the patient to the center of the healthcare efforts, rather than simply have them be cogs in the machine that our dysfunctional healthcare system has become.

Let’s give it some time.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • John C. Key MD

    I’m concerned that Dr Pelzman is too heavily invested in the PCMH milieu to view it with anything near objectivity. To most of us more removed from the scene, it was an obvious non-starter from the get-go. “Too many cooks spoil the soup”, we were taught, and it is hard to see how bringing a lot of cooks into the patient care kitchen can yield a better result. When I was a student, HMO’s were to be the primary care savior; then PPOs, then PHOs, then mid–level practitioners, and now on to ACO’s and the vaunted PCMH. All have failed and all will fail. The farther you get from a doc-and-a patient, the more dissatisfying it becomes for all.

    • SarahJ89

      I want a relationship with ONE doctor, not a “team” of people I don’t know and don’t want all in my business.

  • Dr. Drake Ramoray

    The only objective data this piece provides is on how PCMH doesn’t work. The rest of it just reads like a desperate plea from someone who wishes for something that isn’t.

    “Does it ultimately save money, save lives, and improve outcomes? Absolutely.”

    So you say but not the study you cite. What ever happened to evidence based medicine?

    I’ve got a practice algorithm for you. Don’t spend money on PCMH it isnt gonna work.

    • PrimaryCareDoc

      Exactly. Where is the evidence that it saves money and lives and improves outcome? There is none.

      • LeoHolmMD

        Lets not allow evidence to stand in the way of sound bureaucracy. These people have desks to surf and grant money to snort. If you want to be concerned with money and lives, go form your own accreditation agency or profession or whatever.

    • NPPCP

      Right, don’t listen to the voice coming out of the speaker on every corner that says, “there are no corners.”

    • NewMexicoRam

      Reminds me of the shopper who took all their coupons to the store, bought a bunch of stuff, and took it all home to thier spouse. After peeling the spouse off the ceiling, the shopper said, “Well, we may now be broke, but look at all the money we saved doing it!”

  • guest

    As far as I can tell the main goal of the PCMH is to turn doctors into mini-healthcare administrators, with most of the doctor’s work being directed towards the “management” of metrics and tasks related to the patients’ health.

    The biggest problem with this is that it’s not really what a patient wants their doctor to be. The second biggest problem is that it’s not what most of us went to medical school to do.

  • buzzkillerjsmith

    Dr. P.’s views have no merit. He is a cheerleader, not an analyst. Just look at the blog name. Ignore this knucklehead.

    More interesting is the article itself. In terms of utilization and costs, none of the p values between the pilot groups and the control groups was significant. Not one. Flip a coin.

    In terms of “quality,” the only significant difference between pilot and control groups was that the pilot groups did better at diabetic nephropathy screening. With all due respect to the eminent endocrinologist at this blog, I kinda would have preferred having the Chlamydia screening rates as the main difference. But that’s just me.

    The good news is that the PCMH and it allied insanities have given us docs the opportunity to spend several extra hours per day farting around with computers for no apparent purpose except perhaps the intrinsic joy of it.

    The editorial is also worth a read. It starts off pretty well, making some good points about methodological shortcomings but then stating that the evidence so far shows that the PCMH is essentially useless. Quite true. A choice line, with which most of us can agree: “Widespread implementation of the PCMH with limited data may lead to failure.”

    But then, perhaps inevitably, the editorial itself drifts in knuckleheadland by stating that maybe we should just adopt the PCMH to address the needs of expensive and complex pts, the supersickies. “…detailed health risk assessments; integrated and intense comorbid disease management programs,” outreach and monitoring and blah, blah, blah. You all know the rest, have heard it for years, if not decades.

    Of course docs should try to take care of supersickies. But how the heck do we know if an integrated approach to this will save money? We don’t. It would be an experiment. Would it improve care? Maybe. I guess dying in 9 months instead of 7 is a statistically significant difference. And why do we have to call this latest dance craze, if it comes, PCMH? How about the SSICC, supersickie intensive care craze?

    Can smartphones and team members and home visits keep heart failure pts who are always a half-bag of potato chips away from decompensation out of the hospital often enough to pay for all the smartphones and team members and home visits? I’ll lay odds they can’t.

    • Dr. Drake Ramoray

      I’m very happy with the low incidence of screening for Chlamydia required in my practice (don’t give the bean counters any ideas) thank you very much. ;)

    • NPPCP

      And we should notice that Pelzman never responds to any of these posts. He can’t type with a pom pon in each hand. I listen to nothing he says. He is a paid shill. If he weren’t, he would be openly engaging in this conversation.

      • southerndoc1

        “He can’t type with a pom-pom in each hand”

        Great line!

      • PrimaryCareDoc

        I agree. Why isn’t he here responding to our concerns? It is emblematic of the entire fiasco that is the PCMH. Ignore those on the front lines. If people have concerns, pretend you don’t here them. Don’t look at the man behind the curtain!

  • southerndoc1

    Shorter version:

    I’m the recipient of a multi-million dollar federal grant to establish a residency-based PCMH (as per Dr. P’s blog), so I don’t care what the evidence shows.

  • NPPCP

    I love this. One of my favorite pieces of advice I routinely dole out is “you are an adult – you know what to do”.

  • http://helathecommunications.wordpress.com Steve Wilkins MPH

    What has always struck me as odd about these PCMH pilots is the
    presumption by plan sponsors that infrastructure modifications like registries, team care, extended hours and embedded care managers would lead to better quality care, increased engagement or exceptional patient experiences. There was never any evidence to support that
    presumption.

    Rather, evidence over the last 30 years has shown that the
    adoption of patient-centered care – which really translates into
    patient-centered communications – is what leads to improved engagement, better quality outcomes, lower lab test costs, fewer ER visits and hospital readmits and better patient experiences. Yet these softer aspects of patient-centered care are basically ignored by PCMH credentialing agencies.

    In a recent piece I did on my blog Mind the Gap I described
    how PCMH providers were no more patient-centered in terms of their patient communication skills than their non-PCMH counterparts. In a comparison with AHRQ’s CHAPS data I showed how PCMH satisfaction scores for physician communication were lower for PCMH providers than all physicians most of which don’t practice in a PCMH Model
    practice.

    The bottom line is that it is way too early to be throwing the baby out with the bath water with respect to the PCMH care delivery model. As PCMH moves beyond the “building to spec” mentality perpetuated by NCQA and other accreditation agencies…and as PCMH become truly patient-centered” in ways that make a difference, e.g., patient communications, they will much better able to deliver on their original promise.

    “Building a medical house to spec is not the same thing as crafting a patient-centered medical home.”

  • ninguem

    Am I the only one reminded of the Ministry of Silly Walks?

    http://www.youtube.com/watch?v=IqhlQfXUk7w

    I’m sure if Dr. Pelzman got government backing, he could make the PCMH far more silly.

  • LeoHolmMD

    The payers are not going to give it any more time. Then it will be defunded or underfunded, much like the current situation in Primary Care. Then it will really fail. Then everyone can shut up about it.

    • buzzkillersmith

      Your point is key. Rhetoric aside, the payers care only about the costs, not the improvement in screening for kidney disease in diabetes. Pulling the plug is a definite possibility. Unfortunately some other moronic program might take its place.

      My plan is to identify the next moronic idea early on so as to become a shill for it and thus get off the hamster wheel.

      • NPPCP

        I would like to be in on the ground floor as well. I would like to be the public relations specialist – any criticisms will be fully addressed in the following press release which will be repeated over and over until it becomes truth: “absence of evidence encourages us to evaluate evidence absolutely in an evidence based manner while validating any potentially missing evidence with the understanding that evidence in absentia can be validated by presumptuously asserting its validity is sound and will be proven eventually.”

        • PrimaryCareDoc

          Beautiful!

  • LeoHolmMD

    “When Dr. Semmelweis first found that washing your hands decreased the rates of puerperal fever in their obstetrical practice, he did not do a cost-benefit analysis. Most people did not believe he was onto anything. And in the more than 150 years since then we have gone on to improve sanitary conditions in healthcare up to the ultrasterilized operating rooms where not a single microbe can survive.”

    Dr. Semmelweis noted an observation, formed a hypothesis, and perfected a technique based on science. Is that the way the PCMH was formed?

    • PrimaryCareDoc

      Excellent, excellent point.

  • NewMexicoRam

    Gee,maybe if we just buy more lottery tickets and try harder to pick the right numbers, we just might win!