Thursday, June 30, 2011

It's Not News: The Uptake Of The Patient Centered Medical Home (PCMH) Remains Low In Small Physician Practices: Some Good Options Are Available

Looking for that medical home
Given its near-mystical aura of quality and cost savings, endorsements by rock-star expert academics and enthusiastic prominence at D.C. health policy meetings, anyone who doesn't read the Disease Management Care Blog can't be blamed for believing primary care physicians must be flocking to the Patient Centered Medical Home (PCMH).  Regular DMCB readers know differently.  They're still skeptical about the science, have little use for academics who don't do night call and understand why regular doctors are too busy to attend multi-day oxygen-deprived meetings in swank hotel basements.

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.


Christopher Langston said...

Thanks for bringing some realism to the PCMH premature-victory party being held in DC and all over the country.

At this point we should all know that becoming a PCMH is extremely daunting even to providers who want to do it. It requires substantial costs of time and money, culture change and re-training and re-deployment of personnel. In the short term, the disruption will make everything worse (even if it is only because of the days lost to patient access/billings from having providers in hotel basements).

(BTW did you see the new Federally Qualified Health Clinic Advanced Primary Care (PCMH) demo will be paying $6.00 per Medicare beneficiary per month - I'm not sure what a FQHC is supposed to be able to afford with that generous offer (after completing the paperwork) that would allow them to improve patient care, but I'm really curious.)

(Sarcasm on)
And worst of all, all PCMHs really offer is an uncertain chance of better patient care. The economics of it probably still doesn't do much of anything for primary care physicians' paychecks. (Sarcasm off)

Yes, we need to front cash and assistance to primary care practices. Yes we need to pay more for primary care services, putting our money where our ideological mouths are. We even do need substantially more research as we go along to help refine models and guide the process. (E.g., I don't think the evidence favors your notion of outsourced care management, but we should try different things and see what works for whom under what conditions.)

But nihilism and inaction are not the answer. Can anyone believe that EHRs, registries, care managers, efficient team work, etc are NOT required, essential components of a more effective health care system?

If well educated, well paid MD, refuse to look past their short term self interests and invest in the future of health care, who do they think is going save the day? This country needs better primary care and primary care providers need a better deal - nobody wins if we stick with the status quo.

Jaan Sidorov said...

Bravo Christopher L!

If you define "outsourced care mgt" as "disease mgt," there are some recent publications that credibly show savings vs. usual care (not the least of which is Health Dialog's data in the NEJM). Their problem is that they didn't put "PCMH" in the title, so they're going largely unseen by the dominant policy wonks.

$6 is silly, isn't it, especially when the initial CMS plan for the Medical Home was considerably higher. This is CMS' latest demonstration of innovation and partnership?