|Looking for that medical home|
That's why DMCB readers won't be surprised by the just published on-line Health Affairs article that shows "Small and Medium-Sized Physician Practices Use Few PCMH Processes." Diane Rittenhouse and colleagues conducted a 40 minute telephone interview called the "National Study of Small and Medium Physician Practices" on 1,344 clinics operating with 1 to 19 physicians with at least 33% in working in primary care. This represented a healthy response rate of 63%.
The survey used a 17-point system to assign an overall score. It focused on the presence of PCMH-style teaming (defined as regular staff meetings to discuss the care of a group of patients), coordination as well as integration of care (including electronic records and registries), a focus on quality and safety (including decision support, quality improvement, performance feedback and patient education) and access (not only appointments but email and telephone communication). The survey also asked about the presence of nurse care managers.
And guess what? On average, survey participants achieved about 22% of the possible points. Points for teaming averaged 28%, use of an EHR was 26%, 9% met criteria for having a registry, 9% used patient e-mail and a whopping 3% had nurse care managers in place to counsel patients for chronic disease. Smaller practices were more likely to not meet PCMH criteria, but even then, the average score was 33% in the larger practices with 12-19 docs. If monetary incentives were in place, the uptake was greater, but even then, the mean improvement was only about 10%.
To the authors' credit in the Discussion part of the manuscript, they recognize that just because the PCMH seems nifty is no reason to expect its wholesale adoption. Assuming the PCMH lives up to expectations (still a big if), they point out the PCMH will need lots of assistance (grants, loans and training), shared resource planning (care managers could be funded externally, for example by insurers and shared by the clinics), incentives (P4P and risk contracts) and a new generation of differently trained docs.
The DMCB wholeheartedly agrees. It also points out that it's gratifying to see Dr. Rittenhouse and colleagues bring up the "shared services" model as an important option that will increase patient access to the care management function of a PCMH "style" of practice. They can read more about that here. Absent any evidence to the contrary, the DMCB doubts the average physician has any real sense of PCMH ownership and would be happy to outsource much of it.
Given the dismal uptake of the PCMH, it's time for health policymaking to recognize that.