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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