Wednesday, May 13, 2009

Red Flags on the Patient Centered Medical Home

The grateful Disease Management Care Blog was alerted to this must-reading paper from the latest Annals of Family Medicine for anyone interested in the patient centered medical home (PCMH). The physician-authors (Paul Nutting, William Miller, Benjamin Crabtree, Carlos Roberto Jaen, Elizabeth Steward and Kurt Strange) are from a spectrum of institutions and were asked by the American Academy of Family Physicians (AAFP) to evaluate their National Demonstration Project (NDP). The NDP was kicked off by AAFP to pilot the PCMH over two years. It took place in 36 family practices and closed in June of 2008.

The news is not good. Some of the literature and much of the policy on the PCMH would have you believe that physician interest is high and, if it weren’t for mean-spirited insurers, change would be easy. That ain’t necessarily so. While the data are still being analyzed, the authors have gathered enough information to ‘identify some potentially red flags’ for the other demonstrations that are underway.

Each of the red flags are summarized below.

The PCMH requires epic levels of transformation – The redesign of a primary care practice site involves complex and interdependent practice functionalities that range from scheduling to patient access to decision support to other domains. This is a 180 degree turn from supporting ‘physician workflow’ to ‘patient experience.’

The necessary supporting technology is not plug-and-play – The addition of registries, e-prescribing, patient portals and other technology to the core PCMH-friendly electronic record are far more difficult and time consuming than generally appreciated. Work-arounds were common.

This involves the personal transformation of physicians – Changing docs away from authoritarian, scienced-based, one-patient-at a time physician-centered style care to patient- goal focused, collective and team-based style care runs counter to years of training and years of socialization. It doesn't sound like a fee schedule update is going to do it.

Change fatigue is a serious concern. It’s not uncommon for the process to be plagued by fits and starts with unanticipated ripples that buffet every corner of the practice. While there are gratifying breakthroughs, they are not enough to preserve the very fragile momentum.

The developmental process requires 'adaptive reserve' – Just because a practice is well run and enthusiastic about the PCMH doesn’t mean they have sufficient ‘adaptive reserve.’ Physician-led ‘just do it’ tactics don’t work over the long run. What’s more, if there’s any dysfunction in the practice, you can count on the transition to a PCMH to bring it out.

Change is local – Transformation depends on the uniqueness of the practice, the system and the community. Multiple paths lead to the PCMH and no one size fits all.

Based on these red flags, the DMCB:

....wonders if the PCMH, as currently envisioned, is out of the reach of most community based physician owned practices. The financial and change management support may likewise be out of reach for government and health insurers no matter how much they want to see it happen,

....has doubts, based on the tone of the paper, that the NDP PCMH pilots achieved any reductions in claims expense. Hopefully, healthcare reform that includes the PCMH will pass before the economic analyses from all the pilots become available,

....suspects the disease management community will probably be the least surprised over the description of physicians as authoritarian, science-based (vs. patient-goal based), and fixated on one-patient-at a time style care. Indeed, this is the first recognition in the care management literature that doctors may not be completely innocent when it comes to the gulf between disease management and the physician community.


Aaron B. Hicks said...

Rome wasn't built in a day, and changing how providers approach health care will be no different. The points from NDP analysis serve as evidence that implementing the principles of the PCMH will be no different.

However, the NDP did not address the value of training new health care providers under the tenants of the PCMH. Sure, it's difficult for seasoned providers to drop their old methods and adapt to an entirely new system. But freshly minted health care workers and physicians, just entering their fields, are much more impressionable.

I still have hope for PCMHs even though I share many of the same doubts about their short term efficacy. As long as all players remain progressive and vocal about the end goal, positive changes should come with time.

Jaan Sidorov said...

Aaron raises a good point: it took awhile for us to get to this point and it will take awhile to dig ourselves out. In addition, there is always the prospect of newer physicians adopting the principles of the PCMH in their practice.

While I share Aaron's hope, the cautions are a) the rush to healthcare reform may not wait for Rome, b) it'll take decades for the new physicians to reach a critical mass (assuming we can figure out a way to attract them)and c) we need to be open to versions of PCMH 2.0.