The Medical Home’s Humpty Dumpty Defense

The Medical Home’s Humpty Dumpty Defense

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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 of Health Quality Advisors LLC in Highland Park, IL and the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management. This post originally appeared in Forbes.

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22 Comments on "The Medical Home’s Humpty Dumpty Defense"


Guest
Mar 21, 2014

By all accounts, the principles of the PCMH are sound. However, it’s common sense that layering sound principles on top of a seriously flawed (fee-for-service) model is bound to have troubles realizing the full potential of sound principles. This isn’t unique to primary care or healthcare for that matter.

The far more optimized model *has* been created — they are called Direct Primary Care Medical Homes or Direct Primary Care (DPC) for short. By necessity, it recognizes that an optimized model needs to be built from the ground up. Dr. Rushika Fernandopulle colorfully described too many models as “putting wings on cars and calling them airplanes”. An earlier THCB post highlighted this model — see http://thehealthcareblog.com/blog/2012/04/18/medicaid-driven-budget-crisis-needs-a-marcus-welbysteve-jobs-solution/. In that article from nearly 2 years ago, it suggested using DPC for Medicaid. This is now happening in Washington, the birthplace of DPC with the originator of the concept — Qliance. Further, Qliance has seen explosive growth since the ACA insurance exchanges started. As promised in the little-known ACA clause, when you combine a high deductible wraparound policy with DPC, you have the best of both worlds. No need to burden the equivalent of tune-ups and tire changes with insurance bureaucracy. This is why DPC physicians are stating that they are once again practicing medicine the way they were trained rather than being burdened by so-called “productivity” goals.

Dr. Fernandopulle describes more of his model in this video –
http://watch.knowledgevision.com/cfb78a64059d484b9e3ab5b8eae35349. I haven’t observed or read about any healthcare delivery model delivering a better bang for the buck than models such as his. It’s truly the Triple Aim — better outcomes, lower costs and better consumer experience. Both Qliance and Iora have measured their Net Promoter Score (a measure of customer satisfaction) and are consistently achieving NPS better than Apple or Google.

Google “Hot Spotters Sequel” for more on how they are treating some of the most challenging patient populations yet achieving impressive outcomes. While not as abundant as PCMHs, DPC practices such as Iora, Qliance, Medlion and others are rapidly growing. I heard Qliance grew over 100% in January alone so it’s no longer the case that DPC is a “concept car” — it’s the real deal. If you are interested, contact me via LinkedIn to request the seminal study on DPC. https://www.linkedin.com/in/chasedave

Guest
Mar 10, 2014

Thanks for that information, Marci.

Guest

Thank you Michael for acknowledging that the data in the report itself is correct (and it is the icons in the Appendix that you take issue with).

I authored the PCPCC Annual paper so I reviewed all 20 articles that we cite, wrote the bulk of the text, and constructed all of the tables. You have correctly noted that our paper (in Table 2) refers to the intervention practices in the Fifield article as having attained 3.8% fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year (p=.002) and physicians improved efficiency for all episode types by 3.3% (p=0.07) (among other things they report).

Where you seem to take the most issue is with the icons that were used in the Appendix (these were not in the summary, only the Appendix). It is true that I did not sit at home in the evenings and do the art work for the Appendix (I was writing the paper!), but the staff who converted Table 2 into the art copy for the Appendix thought that the cost savings of $1,200 a year, per physician warranted a green dollar sign icon. I understand your concern and if this is your criticism of the report, that is fair enough. This is easily resolved by better labeling the point of the icons — which are meant to help steer the reader to what can be found within each article/evaluation (which is why we include a link to each original article, for the ease of the reader).

The data within the report, and within each table — if I have done my job well — are correct. You do mention your concern that Table 2 does not refer to the other efficiency measures that the Fifield article analyzed. That is true. But I disagree with your assessment is this makes our report “out of context”. Our Annual Report isn’t a study, it’s an annual report — with an admitted point of view and an acknowledgement that “this report does not represent a formal peer-reviewed meta-analysis of the literature” but profiles a summary of PCMH findings. The findings we report are from both academic and industry — we include as much information about the studies as we can in a single report — but it is not the meta-analysis that you are perhaps suggesting.

I do hope that we are reflective about what the findings mean, however, We summarize that “while we need to be cautious about over-promising what the PCMH alone can deliver, , , our review of the recent literature affirmatively shows improvements across a number of categories. Our review also suggests some gaps in the evidence and ways to improve future PCMH studies. More robust analyses regarding how PCMH’s function, transform and improve outcomes for all patients and their families are critical to the long-term success of primary care, as well as helping the US to achieve much needed, broad-based delivery reform.”

Again, I stand by our report and the data it summarizes, but I appreciate your attention to it.

Thank you,
Marci

Guest

Marci and Paul:

I appreciate the opportunity to go back and re-examine the PCPCC’s annual report. In my blog post, I quoted from the annual report and from the original wording in the paper it summarized. PCPCC’s summary seemed inaccurate. Below, I lay out a series of facts that buttress that conclusion: what PCPCC says this study concludes and what the study itself concludes seem to be different. I invited readers to make their own comparison.

First, to review the summary stuff on Fifield et al., JGIM, June 2013.

The PCPCC summary using icons awards this study a dollar sign for cost savings, a little ambulance for reduction in ED/hospital use and a stethoscope for increased preventive services.

Next, here is the JGIM summary of its findings, which I will not condense: “In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.”

Let’s leave aside here the issue I brought up in my blog post about PCPCC quoting this study approvingly even though it involved “transition” practices, while criticizing JAMA for drawing conclusions about practices that were less than a “true medical home.” (Sauce for the goose, sauce for the gander? Alice in Wonderland?) Rather, let’s look just at facts.

How can PCPCC say there were cost savings in its summary when the actual article says there were not cost savings? That, Paul and Marci, is what I keep asking. Here’s my theory:

If you go to the more detailed PCPCC summary it summarizes the article this way: 3.8% fewer ED visits per year, savings approximately $1,900 in ED costs per physician, per year (p=.002) and physicians improved efficiency for all episode types by 3.3% (p=0.07)

That is certainly accurate. It’s just not in context. ED visits were one of ten efficiency measures. The PCPCC report doesn’t mention that it was the ONLY measure to significantly improve. If the Fifield study had measured 20 efficiency measures and one improved, does that still merit a little $ sign from PCPCC? What about one in 100? One in 1,000? Does anyone think this methodology meets the sniff test?

And even if you focus just on ED costs, the actual study specifically says that, despite the promising results: “There was [cq] no cost savings observed on any cost-of-care measures, including total, ED, hospital admission or outpatient episodes over 3 years.” A bit confusing, given what they say about ED costs in other parts of the paper, but this is very specific. (You can look at the actual paper to see the facts about preventive services.)

Yes, the discussion portion of the paper says encouraging things about the PCMH, including that physicians in the intervention group are beginning to tend the curve. But the actual data are just as I quoted and the authors specifically say that the difference in ED costs seen between control and intervention “MAY become significant” (emphasis added) — meaning it is NOT significant now. In otherwise, the little icon awarded by PCPCC as “evidence” that the PCMH improves preventive services was awarded for a result that the paper’s authors specifically say was not significant.

I picked this paper at random because of the quality of the journal involved.
I have been a peer reviewer for medical journals and had peer reviewed articles published, including, recently, in JGIM. On its face, the PCPCC summary of the Fifield study appears biased and inaccurate.

Obviously, neither of you sat at home on evenings putting together this PCPCC review. But, you’re right, you bear responsibility. Given that the PCPCC presents its annual report as an accurate summary of PCMH evidence, I would hope that the leadership of PCPCC would commission a review of that evidence.

Guest
Mar 9, 2014

Michael on the plane leaving for Australia as i type but very happy to chat. I do stand by the report and very happy to chat. It would be great if you visited at least some of the practices and had a sense of what is really happening on the ground . I look forward to catching up.

Guest

Strong accusations. As first author I am ultimately responsible for the PCPCC Annual Report and any errors or omissions. I stand by it in its entirety, including how the JGIM study was characterized and suggest you read the methods section of our report. Happy to discuss details and answer any questions.

Thank you,
Marci

Guest

Jeff: I agree with you about the changes needed. The problem, however, is not merely the capability of physician practices to change but the recognition that change is necessary. As you know, it took the AMA years to even say the word “guidelines,” instead of “practice parameters.” This fall, Rep. Mike Burgess, a Tea Party Republican active in the GOP doctors’ caucus, talked at Brookings about the need to think about the solo practitioner in Horseshoe, TX. The bureaucracy that stops adaptation to the future is only an issue if you’re trying to adapt.

Paul: While I appreciate your defense of the PCMH, you, like Marci, did not address the topic of my blog. I was not talking about the PCMH, I was talking about the PCPCC’s defense of the PCMH. It included misleading statements and misleading or completely inaccurate characterizations of the medical literature.

Since you are a respected thought leader, corporate executive, PCPCC board member and physician, I hope you would address those questions rather than talk about a different topic the way politicians do when they want to change the subject. The JAMA study may or may not be definitive. The tactics used by the PCPCC in your name — the name of the leadership — to respond to that study are nonetheless highly questionable. If someone who reported to you at IBM characterized IBM research as inaccurately as PCPCC characterized the JGIM study I cited, you’d fire him.

I’d be happy to discuss that online or off.

Michael

Guest
Mar 8, 2014

So 8 year ago IBM and 47 other large employers asked the house of primary care for a change of covenant between the buyer and the provider of care we wanted to stop buying an episode of care and instead buy the ability to manage a population supported in a healing relationship of trust.

we want to move from to the following —> to a future state .

My patients are those who make appointments to see me –> Our patients are those who are registered and you are responsible for them as a population. .

Care is determined by today’s problem and time available today –> Care is determined by a proactive plan to meet health needs, with or without visits …

Care varies by scheduled time and memory or skill of the doctor –> Care is standardized according to evidence based guidelines and advance clinical decision support ..

I know I deliver high quality care because I’m well trained –> We measure our quality and make rapid changes to improve it ..

Patients are responsible for coordinating their own care –> A prepared team of professionals support the coordinates of patients’ care

It’s up to the patient to tell us what happened to them in the ER –> We track tests and consultations, and follow-up after ED and hospital

Clinic operations center on meeting the doctor’s needs –> A connected interdisciplinary team works at the top of our licenses to serve patients

We the Buyers asked the House of primary care to give us a set of principles to make this transformation to proactive primary care on.. out of that request was born the Joint principles of the PCMH was born the the idea is not a model is it rather a set of principles built on the commitment from the house of primary care to deliver proactive healing relationship base advance primary care.

The PCPCC was created as a collaborative between buyers and providers to advocate for the delivering of this change covenant.

How do we view the pilot from 2008 to 2011 only for what it was designed to tell us Ie will this fly — can practices transform and become proactive vs reactive using one diease Diabetes as a model . The answer was yes but it is hard. Was this pilot deigedn to answer the question will it save money well no!! I have visited most of the practices and the major payers it will never turn back. On that base we have moved on. Do you home work go visit the practices in Se PA that are on the journey ask what they have learned where they are where they are going and come back and blog that .

Now lets look at what the payer has to say about 18 months after this 2011 pilot ended and they had rolled out.

http://medicaleconomics.modernmedicine.com/medical-economics/news/study-pcmhs-lower-costs-patients-needing-chronic-care . By Aug 2013 the largest payer is reporting this about the Penn PCMH pilot Blue Cross (IBC) found “significant reductions in medical costs for patients with chronic conditions treated in primary care practices that have transformed into medical homes,” The results were especially striking among patients with diabetes, which is one of the nation’s most prevalent and costly chronic diseases. These patients saw a 44% reduction in hospital costs and a 21% reduction in overall medical costs. Diabetic patients treated in the studied PCMHs also saw a 60% improvement in getting their low-density lipoprotein levels under adequate control. Overall, the number of patients with poorly controlled diabetes declined by 45%, according to IBC. In addition, patients with diabetes were more likely to receive key tests such as eye exams, blood sugar levels, and kidney function compared with patients not treated in a medical home. IBC’s studies evaluated 125,000 patients receiving primary care in 160 medical home practices in southeastern Pennsylvania.

The PCMH concept emphasizes a team approach to delivering primary care and close coordination among all providers, including primary care and specialists, as well as non-physician providers. The goal is to reduce hospital readmissions and eliminate redundant tests and procedures.”

There are now dozens of studies being carried out many with very positive results some with less positive results. Lets look at the evidence not jump to conclusions based on 32 practices in a study that was not designed to answer the question about.cost and quality by 2011

Yes this study ending in 2011 did not — as pointed out by the lead author answer the question on PCMH quality and cost but than it was not designed to do that. It rather was designed to as the question before that can practice transform and became a place where a population can be proactively managed from. When the Principle author Dr Friedberg was asked in the JAMA about cost reduction or quality improvement Dr Friedberg said “I don’t think this study can answer that.” … “Hopefully, in a couple of years we will be in a position to say x, y, or z are necessary for a successful medical home. “I think it would be a mistake to say, based on this study, that the model can’t work”.

http://newsatjama.jama.com/2014/02/25/author-insights-limited-quality-improvement-but-no-cost-reduction-in-medical-home-pilot/?utm_source=H2RMinutes+PCMH-ACO+Mar.+4%2C+2014&utm_campaign=PCMH-AC+Minutes+2%2F25%2F14+&utm_medium=email

You bet we advocate for care at least as good as my cat gets when it is notified of it immunizations in a proactive way because the Vet has a register – yes we do you bet!! You see e my family is now in a medical home and it saved my wife’s life because she was notified of her mammogram.

Have an idea better than advance Proactive primary care as a solid base to deliver better care on — great bring it on. But FFS for an episode of care that is not coordinated, not integrated, not accessible not comprehensive we do not want to buy only that any more it has failed us we think of it as a milking machine . Look we have employees that have 5 specialist all Rxing 5 different medication with no coordination it kills. We the buyers want a change of covenant. from the providers and when we asked for that the Joint principles of the PCMH is what we were given.

Do we expect every pilot to go perfectly heck no. But what we learned in PHl has really help us and we have moved on. go talk to the practices now see where they are at 2 years after the Jama study.

Guest

Jeff, you misremember my many, many talks entitled “Quality or Else.” I have consistently urged physicians to lead the quality improvement process or the bureaucrats would do it to them.

So you and I are on the same side. Oh, wait: unless, perhaps, with your University of Chicago training, you’re siding with the Richard Posners of the world who see any regulation whatsoever, including those nagging requirements for fire doors and the like, as unnecessary government intervention. Me? I’d rather not barbecue patients to prove a point.

The history of quality regulation is absolutely clear: doctors are given total freedom, they abuse it and regulators step in. Democrat and Republican, conservative and liberal. Medicare took effect in 1966. By June, 1967, the AMA was begging physicians not to abuse “usual and customary.” To no avail.

At least with the NCQA requirements being online fewer trees are killed.

MM

Guest
Jeff Goldsmith
Mar 9, 2014

Nope. No Posner here. What is missing is a diversity of models that actually fit the care and info needs of patients. What % of patients need one a medical home. I don’t need one, nor do you. For some, like Atul’s super users, the medical home isn’t enough. They need help getting their lives back together.

It’s people with unstable full onset chronic disease that really need a medical home, and for a lot of them, not a primary care driven one, but one focused around the specialized expertise needed to manage their specific risk.

This brilliant clip from the University Hospital Consortium displays the targeting problem and some solutions: http://youtu.be/50SlzKDfHVU

Not sure who you were addressing in the medical community, but state and local medical societies or, for that matter, hospital medical staffs, were poorly equipped to deal with this. You really need “organized medicine”- IPA’s,
multi-specialty medical groups, Kaiser/Group Health entities, etc.- to pull thus off.

Getting medicine organized to accept and manage the lumpy, sub-population risk was a precondition to doing this.

What does it cost in TIME to get certified and keep the NCQA certification? Most medical practices just don’t have it. Caregiver time is a lot more expensive and scarce than trees.

Guest

This study and a meta-analysis of PCMHs last year in Annals of Internal Medicine show that the PCMH is a deeply flawed model that should be largely abandoned.

EMRs have amounted to nothing more than an extravagantly expensive boondoggle that has just traded one set of quality/safety problems for another (handwriting errors eliminated; copy/paste errors are here). Disease registries are not useful broadly applied. Primary care doctors have turned into demoralized box checking drones for measures that are largely meaningless. They undermine the very essense of effective primary care: individualizing care for complex patients.

The triple aim is not achievable with most of the PCMH measures. Most of the box checking leads to higher costs if the services are more often provided (mammograms, cholesterol screening, etc.).

Family physicians deliver better care at a lower cost compared to specialist care by how they manage acute symptoms and chronic conditions. They save money by NOT doing things to people, by NOT exposing patients to the harms of over-testing and over-treatment. This concept is not mentioned in the PCMH, especially the NCQA version. If a patient calls a clinic reporting chest pain, how does the physician react? Does he/she talk to the patient a moment to see what’s going on, trying to get the patient to come to the clinic if at all possible, or does he’she say, “go to the ER.” That’s the rub. That’s an example of the crucial difference in care approaches that are nowhere to be found in the PCMH.

Time to dump the PCMH and move on to models that actually pay family physicians to provide comprehensive care of complex patients.

Guest
LeoHolmMD
Mar 9, 2014

Bingo. Turning the whole world into a chronic disease management program is going to send costs through the roof. The PCMH does not address where the real expenditures are. Too busy distracting Primary Care.

Guest
Mar 11, 2014

Dr. Holm,

The others seem to be ignoring us, but we can still have a nice conversation.

Their comments illustrate the fundamental problems of allowing industrialists to try to improve primary care. There are lots of problems with their overall worldview, but let me highlight two:

First, their is a fundamental lack of understanding of 39 years of medical cost-effectiveness research. They assume that doing all of these screenings and preventive work will save money, when in fact it won’t (unless only high-risk patients are targeted for the extra attention). Sometimes the triple aim can be acheived in healthcare, sometimes it can’t. It can if the service is expensive, high-risk, but otherwise routine, such as a knee or heart valve replacement. If you look at the recent study of the lack of PCMH success in PA, all of the qualtiy measures they actually measured, but only 1of 13 got better, all of them raise costs in the long-run, not lower costs.

The second problem is that the industrialists assume that models from industries such as the airline industry are applicable to primary care. If patients all looked and acted the same, that might be true, but as we know they are not. The result is the demoralizing effect of the PCMH where patients don’t want to take their pills or don’t want a mammogram, but we are not allowed to respect those choices without it affecting our quality scores.

My favorite quote about this came from the former President of the Royal College of General Practitioners, Iona Heath, who wrote (something close to this), “The authors of the King’s Fund paper (calling for more measurement and standardization in British GP-dom) treat patients as unvarying units of healthcare demand, one indistinguishable from another. What they fail to acknowledge is that patients can be abusive, manipulative, and self-destructive.”

I’m glad I have a job that is more complex than building an airplane. I just wish the industrialists realized this.

Guest

I agree, Marci, that the recognition program is problematic, to say the least. On the other hand, one cannot logically cite studies that are favorable for the PCMH using current-evolution models and then object to studies that are unfavorable to the PCMH because…they use current-evolution models. Hence my Alice in Wonderland analogy.

Moreover, your comment does not address the most troubling aspect of my blog post. The fact that the annual report of an organization headed by someone like yourself, with respected academic credentials, and with a board filled with similar individuals, has inaccurate and/or highly questionable characterization of research results is very troubling. I picked one report at random. I would suggest that an independent review of all the studies PCPCC cites and the way your annual report summarizes those results would be appropriate.

The PCMH is an important concept, and the PCPCC should be an important partner in developing it. That’s a good reason to clear things up.

Guest

Just a point of clarification. It is true that the PCPCC advocates the PCMH model or philosophy of care. It can be a quite long journey for a practice to get there. Many practices feel like they’ve stepped into the Alice in Wonderland story when they begin the recognition/certification process: it can be confusing, tedious, and transformational change is often tiring and hard. But as in the book, the important part is the *journey* and what you learn along the way. Just because a practice says they are a PCMH (or to draw out the analogy, they’ve read the book), doesn’t mean they have truly transformed to offer provide well-coordinated, patient-centered, team-based whole-person care (i.e. learned the lessons that lead to transformation along the way). It turns out to be far more than a “check the box” endeavor. Our point is merely that. Some practices make the journey to PCMH but don’t go through recognition (maybe there are no incentives to do so in their marketplace). Others go through recognition, but don’t make the cultural and leadership changes to transform.

The full paragraph is below — and we’d welcome your continued feedback on our Annual Report http://www.pcpcc.org

“Although recognition programs have similar standards for assessing “medical home-ness” (Burton et al) the specific elements, processes, administrative burden, and costs for undergoing recognition differs fairly significantly across programs. Moreover, recognition as a PCMH is not synonymous with being one. As McNellis et al describe in their commentary of several primary care practice transformation studies, “a practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH.” Indeed, although a number of the individual elements of the medical home are well-grounded in the literature, the evidence base for which components of the model are most important in terms of impacting patient outcomes, high performance, operational feasibility, and sustainability, is still being developed. Accordingly, the requirements for recognition are also likely to evolve. A persistent challenge is not only meeting the “basics” of medical home recognition, rather, it is the capability of practices and health systems to self-sustain their improvements and adapt their primary care model in response to the changing health needs of patients and the ever-evolving health care landscape.”

Guest
Jeff Goldsmith
Mar 8, 2014

The recognition process is part of the problem. These are the standards:
http://www.ncqa.org/portals/0/Programs/Recognition/PCMH_2011_Data_Sources_6.6.12.pdf

The survey instrument is 57 pages long. Wait: the 2014 Guidelines will be out in March! Expect it to be longer. Like virtually every new federal “quality” initiative, it’s divided into multiple zones and each zone has its set of “core measures”.

Recognition is an industry, a huge revenue opportunity for NCQA, a well meaning but ultimately self-interested organization. It is not surprising that we cannot find a meaningful empirical relationship between all this box checking and actual better outcomes.

Michael- YOU DID THIS, DUDE!

This is how an industry legitimately concerned about quality covers its ass, and wastes millions of hours of clinician time that could be spent caring for usl

Guest
LeoHolmMD
Mar 9, 2014

Wait until you see the new guidelines for getting a “Worlds Greatest Dad” coffee mug.

I agree, this is falling into vanity service territory. I am always amazed at the thousands of Top 100 hospitals there are.

Guest
Granpappy Yokum
Mar 6, 2014

Great post. Thank you.

Guest
Perry
Mar 6, 2014

Policy makers tend to like a “one size fits all” solution, especially to health care. Let’s all have the same basic insurance, let’s all have a PCMH, let’s have protocols and practice guidelines every doctor should follow and maybe be penalized if they don’t. Let’s all have EMR, but if it doesn’t work well for the practitioners or communicate with other systems that’s OK.
While it is not unreasonable to study options for the optimal delivery of health care, it is important to remember that not all doctors, patients and diseases are alike, and we need to allow physicians some leeway to practice as they see fit for their patients. THAT is patient-centered care.

Guest
Saurabh Jha
Mar 6, 2014

I am with you. But this is where it gets tricky.

No evidence of success in policy means one of the following: policy is a bad idea, policy was not tried properly or more evidence is needed. For many the first tends to be a diagnosis of exclusion. Infinite exclusion.

Guest
Granpappy Yokum
Mar 6, 2014

“No evidence of success in policy means one of the following:”

And it also means that those who claimed, with a total lack of evidence, that the policy would without doubt be successful are probably morons and/or whores.

Guest
Perry
Mar 6, 2014

I do see PCMH as a possible solution to certain patient populations, and I do believe in this case it’s too early to tell. It just bugs me when policy makers think that one solution fits all practices.