The American College of Physicians Says the Patient Centered Medical Home Needs Further Research

The Disease Management Care Blog wishes it could give the topic of the Patient Centered Medical Home (PCMH) a break. It was planning to view and comment about the NEJM’s on-line Shattuck Lecture, but was waylaid by the well-written, if formulaic, JAMA commentary on the PCMH by the ACP’s Michael Barr. The DMCB cannot let this one go by.

In the opinion of the DMCB, this well written piece should now serve as ‘the’ reference on the topic of the PCMH. Just two pages long, here is where you’ll find the concepts, the jargon and the key citations to meet the needs of any college paper, RFP, literature review, manuscript, press release, research proposal or business plan. The editorial also follows a now-standardized recipe useful in any health care policy kitchen:

First, describe the heartbreak of unwarranted variation, the ruination of runaway costs, the unfavorable comparisons of U.S. medical care in other civilized countries and the moral bankruptcy of an inequitable, ineffective, inefficient and unsafe health care system. Set aside and preheat to 350°.

Second, in a large mixing bowl, darkly explain that despite the association of strong primary care networks with efficiency and quality, it is being buffeted by poor reimbursement, an inability to attract medical students and a failure to meet the present and future needs of the elderly boomers.

Third, add a hefty helping of the learned and unprecedented unity of the organized primary care groups over the concepts of the medical home and the chronic care model. Then unwrap the term ‘Patient Centered Medical Home.’ Next, depict the unstoppable alliance of the physicians and large employers and its sponsorship of countless Learning Collaboratives. Imply the likely success of the Medicare Medical Home Demonstration Project and then add many other commercial demos being performed with input from health services researchers that will measure quality, cost, patient experience and satisfaction. Combine all ingredients together in a large accommodating and receptive pan. Bake until done.

Fourth, sprinkle with the NCQA Recognition program and the glowing reviews of entities like the Commonwealth Fund. Serve up with a demi-glaze of dissatisfaction with the current system, fiscal non-sustainability, the shame of persistent health disparities and the uninsured, the impending collapse of primary care and the irresistible luster of new improved models of health care.

But seriously, while Dr. Barr followed the standard recipe, this stellar article not only updated the reader on the favorable features of the PCMH and its progress to date, it also made two excellent points:

The first is the PCMH still warrants testing, not implementation. While the entire editorial (as well as the title 'The Need to Test the Patient-Centered Medical Home') speaks to the need to thoroughly evaluate the PCMH, this particular quote says it best: ‘However, it is imperative to test the model in a credible and transparent way in different environments.’ Hear hear. The DMCB especially likes the idea of transparency.

The second is a confirmation of yesterday’s DMCB ‘rest in peace’ post on P4P and its transfiguration into the PCMH. Once again, this quote says it best: “…payment based almost solely on the volume of care provided – even with a small performance-based component based on measures of quality – will not attract medical students and residents to primary care [or] provide the necessary incentives or capital for physicians to invest in practice enhancements, systems of care or health information technology.’ Enter PCMH.

However, the DMCB still wants to know:

1. By starting off with a litany of all that ails U.S. health care, advocates for the PCMH imply that it is a panacea for cost, quality, access, the uninsured and health care disparities. Recalling that there is much to criticize about the disease management industry’s past missteps, why aren’t the PCMH devotees also learning about the perils of over-promising and under-delivering?

2. While traditional ‘primary care’ is associated with lower cost, higher quality and less variation, what evidence is there that a fully implemented PCMH in the same primary care network will lead to even lower cost, even higher quality or even less variation? Why not seek to simply replicate the good primary care we know works into areas of the U.S that need it?

3. It is implied that the PCMH is not only necessary but sufficient for the resurrection of primary care. While it enjoys the widespread support of physicians, where is the real world evidence that a fully implemented PCMH translates into a meaningful improvement in the average PCP’s personal economic well-being? If there is improvement, where is the evidence that it is enough, considering all the other dimensions of the health care system, to make the average medical student chose a career in geriatrics and not dermatology?

4. No system of care, including the PCMH, can ever afford to remain static. Like disease management, it is destined to evolve, especially if testing (and the market) reveals what works and what doesn’t work. Does the ‘need to test’ the PCMH include recognition that a flexible approach to unforeseen and potentially fundamental changes in the seven principles of PCMH may be necessary?