Thursday, August 14, 2008

The Patient Centered Medical Home Doesn't Necessarily Increase Access to Primary Care

Well, it’s official now. Even though the Disease Management Care Blog has repeatedly noted that providing persons with health insurance is not the same as providing persons with access to care, the the National Association of Community Health Centers, the Governor of Massachusetts and even the pro Massachusetts-style reform folks at Health Care For All have come to that realization.

And nowhere is access more problematic than in primary care. Proposals to increase access have included changing medical education, using non-physicians, expanding retail clinics, increasing physician compensation, using the electronic health record and, of course, pushing the Patient Centered Medical Home (PCMH).

Just how does the PCMH perform in increasing access? Your DMCB took to the peer-reviewed literature and found this interesting quote from Future of Family Medicine Project report on the Personal Medical Home [italics mine]:

‘Because the analysis primarily focuses on the impact of the New Model on physician income under current work hours, it is assumed that any increase in services associated with chronic care patients is offset by a reduction in the physician’s panel size, so that the number of hours worked by a physician remains unchanged.’

Whoa. Reduction in the panel size? The DMCB has experience in primary care and suspects it wouldn’t be unreasonable to believe that there would be neutralizing trade offs. Physicians under the PCMH would have new roles that would mean less one-on-one care, but reliance on non-physician team members should make up for it, right? The DMCB looked at some of the original literature as well as the web sites of the Patient-Centered Primary Care Collaborative, the Commonwealth Fund and the Robert Wood Johnson Improving Chronic Care site for more information about increasing access, and was unable to find any.

The DMCB did find plenty of literature on the salutary impact of Open Access scheduling. This is an appointment management system that opens the clinic to patients without requiring them to schedule far in advance. The PCMH includes (but doesn’t require) innovations such as open access but review of the literature shows a) it’s possible to implement open access without the PCMH and b) may not always work (here and here).

What can be concluded? Based on what the DMCB has found, expansion of primary care in general is good when it comes to access to health care, but there is little evidence that expansion of the Patient Centered Care Model among the nation’s currently available primary care practices will necessarily lead to better access. In fact, the PCMH may lead to a ‘reduction’ in physician panel size. Open Access with (or without the PCMH) may (or may not) - help. If efforts to expand health insurance to the nation’s uninsured are successful, it appears we cannot count on the PCMH to address the mismatch between the availability of primary care and the demand for it.

Do any readers have any information that suggests otherwise?

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