Sunday, September 28, 2008

Hazardous Surgical Approaches to the Patient Centered Medical Home

Remember that Edward Jones commercial where the surgeon uses the telephone to instruct the hapless patient on how to perform abdominal surgery? My colleague Vince Kuraitis over at the e-CareManagement Blog suggests the same may be going on between the expert Chronic Care Model (CCM) intelligentsia over at the AHRQ and the amateur episodic-care focused primary care physicians. Given the richness of the CCM and the complexity of redesigning a primary care clinic, he may have a good point. This is very complicated stuff.

Despite Vince’s admonitions, however, the average primary care physician could decide that the-do-it-yourself “insert peg A into hole B” CCM AHRQ manual is worth a try. In Disease Management Care Blog’s prior post on the topic, it assumed that a physician could do the install. Maybe physicians can, but the DMCB argued that once the new clinical CCM Ver. 1 operating system was booted up, it would bear insufficient resemblance to that Golden-Boy darling of the doctors, that lusty pick of the policy makers, that most admired of the academics, the Patient Centered Medical Home (PCMH). There is significant overlap between the CCM and PCMH, but the two are distinctly different. Accordingly, even if successful, the physician and patients would be stuck with yesterday’s care model. As a matter of fact, it would be far removed from the model that is more likely to succeed: a combined disease management - PCMH approach to care.

e-CareManagement makes another point about the CCM, and that is that the surgery would be partially or completely unsuccessful. The DMCB agrees and believes there are important implications for the PCMH. As I point out in my article on the topic in Health Affairs, the track record of implementation of the complicated multi-faceted CCM in practice settings often results in partial installs that depend more on the local physicians’ preferences and biases rather than a commitment to replicating what is reported in the evidence-based literature.

The same could happen to the PCMH.

What else could account for the tiered 100 point scoring system used by the NCQA’s PCC-PCMH recognition program? As the DMCB understands it, installing ‘half’ of a PCMH is enough to get 50% of the points. Does this mean that this 'Ver. 0.5' install would a) take care of half of the needs of a population, or b) achieve half of the potential savings, or c) warrant half of the case management fee, or d) that 50% fewer patients can be assigned to a practice?

Rhetoric aside, the DMCB does not know if a partial version of PCMH results in any, some or all of the potential improvement that a PCMH is supposed to achieve. Think getting only part of the neurosurgery done or taking out only half of an appendix. The DMCB believes there is no peer reviewed, evidence based literature that examines the outcomes from a partially implemented PCMH.

Coda: When criticized by Gail Wilensky, Harvard economist David Cutler has agreed that the individual elements of tort and payment reform, health IT and comparative effectiveness studies aren’t necessarily associated with cost savings. He argued however, that their simultaneous use is the critical ingredient for success. Is the same true for the elements that make up the PCMH?

1 comment:

Katie Coleman said...

Would love to hear your reflections on the difference between the CCM and the PCMH. Though it may depend on what definition of the PCMH you're using, I'm not so certain that "installing" the CCM wouldn't get you pretty far along the PCMH trail. Group Health's experience with the PCMH = CCM + Care Coordination + Continuity + Access all built in conjunction with a solid EHR.

And, I think the NCQA tool conceives of the PCMH in about the same way. We can debate about the allocation & "must pass" elements of the NCQA PPC-PCMH, but at it's core, I think doing planned, population-based care and supporting self-management & community linkages using a team approach will get you darn close to PCMH-ness. See the Prescription for Pennsylvania as an example of a real-life QI project teaching the CCM and reimbursing based on the PPC-PCMH.