OP-ED

The Medical Home’s Humpty Dumpty Defense


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.

Livongo’s Post Ad Banner 728*90

22
Leave a Reply

14 Comment threads
8 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
10 Comment authors
Dave ChaseLeoHolmMDPaul GrundyJeff GoldsmithRichard Young, MD Recent comment authors
newest oldest most voted
Dave Chase
Guest

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… Read more »

Michael Millenson
Guest

Thanks for that information, Marci.

Marci Nielsen, PhD, MPH
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… Read more »

Michael Millenson
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… Read more »

Paul Grundy
Guest

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.

Marci Nielsen, PhD, MPH
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

Michael Millenson
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… Read more »

Paul Grundy
Guest

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… Read more »

Michael Millenson
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,… Read more »

Jeff Goldsmith
Guest
Jeff Goldsmith

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… Read more »

Richard Young, MD
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… Read more »

LeoHolmMD
Guest
LeoHolmMD

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.

Richard Young, MD
Guest

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… Read more »

Michael Millenson
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… Read more »

Marci Nielsen, PhD, MPH
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),… Read more »

Jeff Goldsmith
Guest
Jeff Goldsmith

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… Read more »

LeoHolmMD
Guest
LeoHolmMD

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.

Granpappy Yokum
Guest
Granpappy Yokum

Great post. Thank you.

Perry
Guest
Perry

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… Read more »

Saurabh Jha
Guest
Saurabh Jha

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.

Perry
Guest
Perry

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.

Granpappy Yokum
Guest
Granpappy Yokum

“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.