Redesign the medical home to thrive in the real world

I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.

The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.

That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group.

“It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”

Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!

But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”

In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean — neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.

It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?

In my continuing pursuit of fairness, I picked an article on that list that was recently published in a prestigious academic medical journal, a near-peer of JAMA. The PCPCC summary of the 2013 study by Fifield et al. in the Journal of General Internal Medicine awards it three colorful icons (a green dollar sign, a red ambulance and an orange stethoscope) symbolizing cost reductions, reductions in emergency department and/or hospital use and increased preventive services.

However, here’s how the authors of the actual study summarized the results of a randomized trial involving adult primary care practices: “Compared to control physicians, intervention physicians significantly improved TWO of 11 [clinical] quality indicators …[and] ONE of ten efficiency indicators.” (Capitalization in the original.) They add, “There were no significant cost savings.”

Hey, who are you going to trust, icons from an advocacy group or your own eyes?

In another criticism of the JAMA study, the PCPCC takes the researchers to task for failing to use “measures related to patient-centeredness.” That’s a curious suggestion if you’re familiar with the literature on that topic. A nationally representative sample of individuals with chronic diseases and physician practices found “no association between PCMH processes and patient experience.”

Another study found “fewer than a third of patient-centered medical home practices engage patients in quality improvement.” A third study found improved patient-centeredness only when “lean” quality improvement techniques were combined with the PCMH.

As I’ve written previously, putting “patient-centeredness” in the name doesn’t make it so.

To summarize what the PCPCC would like policymakers and others to believe: a “true” PCMH might save money and improve care, but being accredited doesn’t mean you are one, not being accredited doesn’t mean you aren’t one and the requirements for accreditation “must continue to evolve.”

In addition, a “fair” study would balance original research in JAMA with the icons the PCPCC uses to characterize research listed in its annual report.

Though these arguments are laced with Humpty-Dumpty logic, that doesn’t mean the PCMH concept is headed for an irreparable fall. There’s widespread agreement that primary care needs to be organized more effectively and that primary care physicians should be paid appropriately for transitioning from fee-for-service to pay-for-value care.

There will be tweaks along the way, perhaps by concentrating on those patients for whom care coordination is most critical (which the PCPCC also suggests) or by constructing a “Primary Care 2.0,” as Paul Keckley calls it.

But today, as in the topsy-turvy world of Alice in Wonderland, the math connected to the PCMH specifics doesn’t yet add up. When four times five equals twelve (as with Alice), it’s tough persuading outsiders that something isn’t wrong.

Rather than denouncing or dredging data, not to mention endangering its credibility with dubious definitions, the PCPCC should heed the advice of Dr. Thomas L. Schwenk, dean of the University of Nevada School of Medicine.

In an editorial accompanying the JAMA study, he writes: “Before confidently promoting the PCMH as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings.”

It’s time for PCMH advocates to travel back through the looking glass and re-engineer the PCMH to thrive in the real world. As Schwenk puts it: “The study… has done a great service for advocates of the PCMH by effectively ending promotion of this care model as a generic, low-level, unselective approach to health care delivery for all.”

Michael L. Millenson is president, Health Quality Advisors, LLC.  This article originally appeared on Forbes.com.

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  • buzzkillerjsmith

    Mr. M’s relentlessly pessimistic rhetoric warms my heart. Because in primary care pessimism indicates good reality testing–nothing more and nothing less.

    His points are well taken. The PCMH is an idiotic mess. An interesting question is whether it is more idiotic and messy than EHRs. I welcome your comments.

    Lest I close on a positive note, I might add that we at Kevinmd already went over all this stuff that Mr. M discusses. Spent a few minutes on it maybe and then moved. But it is good to see it percolate out into the mainstream media.

    • guest

      “Pessimism indicates good reality testing” unless you work in a corporate environment in which case good reality testing equals a “negative attitude.”

      • buzzkillerjsmith

        No doubt. I have worked for CorpMed for a total of 10 years, 6 at Kaiser and then 4 at a CorpMed outfit in Minnesota, finishing up in 2002. I’m a slow learner. It didn’t work out too well.

    • Dr. Drake Ramoray

      PCMH is worse than EMR if only, and probably only, because if the EMR thing was over tomorrow not much would have structurally or permanently changed. It’s the concept of pay for performance and the administrative overhead that forces the arms of doctors into big mega corporations for the PCMH that radically changes the lamdscape of medicine from personalized mom independent practices to medicine being turned into the Walmart experience. Cheap, faceless beuracratic where the providers and patients alike are just statistics of distribution.

      Granted I think the two are intertwined as the PCMH is tough to do without EMR and the data dredging it provides. I could see an EMR that actually could make things better, the PCMH in any form is just a mechanism to diffuse the financial responsibility of patient care from the insurer to the provider. Not too different than how over the years with the help of the government

      • buzzkillerjsmith

        I think you’re right. A simple EHR would work for some practices, and you and I agree that no one should complain about docs adopting EHRs of their own free will.

        The PCMH destroys or at least perverts our practices in so many ways, ways you have just described. I think the worse thing is that it drives us family docs into CorpMed, a horrible situation for us and for our pts. And it does not improve care or save money.

      • Deceased MD

        Extremely thoughtful analysis. The only thing that i think might save medicine is physicians having their own lobbyist group. And of course I am not referring to the AMA-which is analogous to an autoimmune disease for medicine.

      • Deceased MD

        Hi Drake. You are so thoughtful in your postings and i am puzzled by something here. Any thoughts why literally every medical organization under the sun is all on the same page (literally)! about PCMH?

        http://www.pcpcc.org/executive

        It is sort of like voting for suicide. Especially our “beloved”medical societies?

        • Dr. Drake Ramoray

          There is an old saying in Poker that when you sit at the table if you don’t know who the mark is, then you are the mark.

          I am happy to note that AACE is not included in your link. They do a pretty good job of seeing reality as the last national meeting had several modules on thyroid only and going concierge. There is such a shortage of Endos that some thinkers there actually think many rural places won’t want Endos as having one may draw more sickies (ie. if the area has only a few PCMH entities that having an Endocrinologist involved just attracts the sickest, non-compliant diabetics. Better to not have an Endo, plead under served area and see if diabetes can be excluded from a payment formula of pay for performance). How’s that for improving patient care?

          As for the other groups. I have always felt that most of the time the people on the boards or in charge of these physician groups are academic types. Most of them have never run a business in their life, and probably couldn’t run a lemonade stand. The majority don’t make a living from seeing patients and are administrators or researchers first and doctors second. The majority of departmental money comes from research and the government already. Add to that, that most residency clinics are PCMH with constantly changing residents and an attending who supervises their care and they just advocate for wha they are comfortable with and what they know. Never mind there is no resident clinic in the United States that turns a profit or could even stay open without being grafted on to a research center or receive money from the Feds to train residents.

          The last piece is probably irrational fear of SGR. The full cuts would never be implemented because it would have put doctors and hospitals out of business. The powers that be beautifully used it as leverage, and yet again made the AMA look like fools.

          It’s mostly that most physician associations are run by people with no business sense and have an altruistic do gooder streak. In summary, they are the marks at the poker table.

          I for one don’t think medicine, at least not primary care can be saved. My groups only hope is that Endos are so rare and nobody else wants to so our job that we might, just might be able to use our location and rarity to avoid a pay for performance scheme while adding on a research component.

          • Deceased MD

            How about this? “If you’re not at the table, then you’re on the menu.” You know you are so lucky you have a solid medical society. At least they are thinking of you and are on your side. And thank you for the link. Pretty eye opening to say the least. Good to be cautious about getting the worst non-compliant DM cases because all these business schemes would love to eat us for dinner.

            What you say about the AMA being a bunch of academicians is different than what you posted before in a link to a Forbes article about them. Aren’t they making their money on what was it–CPT codes? Not being an MBA I feel quite silly asking but not sure how one can make money on that. But apparently a large fortune.

            The AMA to me (from that Forbes article) made me realize that the AMA is run by MBA’s that, like many schemes these days, generate large fortunes with a valueless product. It is one of the only organizations that I can think of that don’t have to represent their members simply because memberships do not pay the bills. Therefore they are like figure heads or puppets for physicians. They act as if they are working on our behalf but really are working against us. Or at the very best are working to promote themselves as medicine as a business of CPT codes and PCMH models. I use to think they were out of touch as you said but I am beginning to think from your Forbes link that they are clever businessmen that will exploit physicians work rather than advocate for them.

            As for endo’s I think you have some possibly good options . But going concierge does not entirely take the pain away from what is going wrong in the field itself. Sadly it sounds like from a financial standpoint, many endo’s will abandon DM and leave it to less qualified types. It sounds like rural work is problematic too for every MD regardless of specialty because of medicaid/medicare. Well i can understand the thought of moving overseas. hard to believe any developed country could be worse than here. Thank you so much for your as always thoughtful response.

          • Dr. Drake Ramoray

            The AMA is the only one with an MBA arm that makes money off of the CPT codes. They are a special and unique snowflake in the world of useless organizations.

          • Deceased MD

            Thanks for the clarification Drake. Still can’t figure out why the rest follow. Must be a money trail somewhere…

  • Deceased MD

    I can understand why hospitals want to charge for a facility fee even though it ends up harming pt care in the long run. But I don’t understand who benefits from PCMH. No studies required. It causes general mayhem, chaos and inefficiency. Forgive my ignorance but who gains from this? How would this create more income for the powers that be than what already exists. Or are they just really that stupid that they have convinced themselves this will solve the PCP shortage?

    • southerndoc1

      “who gains from this? How would this create more income for the powers that be?”

      It’s very simple, actually.

      The goal of the PCMH and team-based health movement is to permanently destroy the doctor-patient relationship, and disabuse Americans of the idea that they have a right to get their health care from physicians.

      They’re starting out with a “team” of various characters led by a physician, and are already getting rid of the physicians to be replaced by PAs and NPs. That won’t save much money, so the next step is letting MAs lead the team (made up of primarily high-school dropouts). And, ultimately, all you’ll be allowed to do is sit in front of a computer monitor and talk with someone somewhere in the third world. Exactly the same as has happened in so many industries: insurers ratchet down payments (while raising premiums), and Corp Med uses cheaper and cheaper labor. It’s a race to the bottom.

      Infallible rule of thumb: any initiative supported by the AAFP will be bad for patients and very bad for doctors.

      • Deceased MD

        LMAO. Well unlike me, you can at least always work as a comedian as CorpMed takes over the world. But look on the bright side. At least we’ll have brilliant healthcare apps out of Silicon Valley start ups..
        WHen I have the unfortunate serendipitous meeting of CorpMed types ( or their hired help) in person it is even more astounding that what you say rings true. On a recent vacation there were 40 EHR consultants staying at the 4 star hotel -as the woman from Alabama said, “I teach doctors.” I had to ask their training for such an endeavor. One guy was a truck driver who carried bottled water prior. The other guy was a hunter from Oklahoma whose dog attacked his brother in law who just got out of prison. Prior to this, I always figured EHR co. hired IT guys for this. Apparently not so.

      • buzzkillerjsmith

        Dark, very dark. I like it.

        • SarahJ89

          Where’s the flashlight?

      • SarahJ89

        Thank you for this explanation. I keep feeling like an idiot because PCMH’s are supposed to be so wonderful but it really sounds to me like a bunch of strangers up my grill. So I’ve been thinking maybe I just don’t understand the concept. Seems as if I do.

        I really just want ONE doctor. I am not interested in discussing my personal health issues with a bunch of people I don’t know. Nor do I care to get to know them. I’ve worked on “teams” often enough to know how much information slips through the cracks. I don’t trust teams, especially not in the current rush-rush, money grubbing corporate med system of today.

        • dontdoitagain

          Good luck on getting a doctor. Advanced practice nurses are gloating that THEY are going to take over the world. Then when everybody realizes that they are just as expensive as a doctor it will be too late.

          I don’t like the “teams” either. It seems that they can bully you through sheer numbers. All flanking your bed, exam table etc. with their incessant questions which have already been answered and effectively blocking your escape. (recent experience, lucky I didn’t get arrested for running their line on my way out the door ama)

    • LeoHolmMD

      Follow the money:

      http://www.pcpcc.org/executive-members

      Hospitals: increased referrals, increased utilization
      IT: obvious
      Payers: increased surveillance/risk management/risk dumping
      Anyone associated with treatment guidelines: increased utilization
      Certification machines: obvious

      • Deceased MD

        Leo thank you so much for the money trail. First of all, the whole site is sickening with every insurance, medical society all supporting this fiasco.

        I just wondered your thoughts about the insanity. Do you think that the guys at the top are aware of how destructive this is or have they convinced themselves that this is actually a great idea? Or are some bullied into joining? Sorry if i have been burying my head in the sand on this one but it was so painful to even open that link. It just seems mystifying that literally every organization is on the same page. literally.

        • LeoHolmMD

          I suppose they should answer that question themselves, but will not. The medical societies will mention the usual “seat at the table” argument. Lots of ideas look good from a blimp, but look like exactly what you are seeing from the trenches. Otherwise southerndoc is right: one step closer to robo care, patient be damned.

      • southerndoc1

        The chairman of the PCPCC is an executive at McKesson, the parasites who own ClaimCheck.

  • PrimaryCareDoc

    Thank you for this frank analysis. It’s time to accept that the PCMH is a failed experiment.

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

    Michael,

    Great post. I would have to say however that if patient-centered medical homes really were “patient-centered” in the way they communicate with and interact with people (aka patients) then I suspect they would be faring better in outcomes studies such as the ones you referenced.

    The basic premise of patient-centered care is that it begins with an understanding of the patient’s perspective, e..g., their health beliefs, goals, fear, motivations, past experiences, etc. Yet few physicians, including those in PCMHs and ACOs, ask patients fort “their thoughts.” One recent study revealed that less than 20% of practicing physicians i admitted to routinely asking patients what their “perspectives.” Kinda hard to be patient-centered if you don’t know anything about the “whole person” other than what’s in the patient registry, EMR or paper records.

    To my way of thinking, before PCMH can make a difference there first has to be a difference between PCMH and traditional physician-centered practices…and patient registries and embedded care coordinators aren’t patient-centered.

    Steve Wilkins, MPH
    Mind the Gap

    • SarahJ89

      When I hear a title such as “Patient Centered” I know immediately it is not. Welcome to the land of doublespeak.

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