Sunday, August 14, 2011

A Realistic Appraisal of Patient Centered Medical Home, Courtesy of the Robert Wood Johnson Foundation

REALLY close look at the PMCH
While supporters of the Patient Centered Medical Home (PCMH) believe it is the greatest thing since the invention of the poultice, realists may appreciate this more evidence-based examination of the topic by Bob Berensen and colleagues, courtesy of the Robert Wood Johnson Foundation.   Among the take-aways for the Disease Management Care Blog:

1.  There is no evidence that the entire suite of services or "principles" provided by a PCMH improve quality or reduce costs.  Rather, only some do.  Research is needed on which combinations produce the greatest value for patients, and which ones can be jettisoned.  We also don't know if it works in all practice settings (for example, in smaller, physician owned practices) and for all types of patients.

2. Current measures of PCMH rely on survey tools that ask about processes of care.  Given the emerging consensus that real goal of primary care is patient centeredness, it's possible that PCMH "recognition" and "accreditation" will become dependent on patient surveys.

3. Estimates of costs to physicians to become PCMHs run from a few thousand to more than a hundred thousand dollars.  In other words, we have no idea.

4. PMCH fee schedules can take a number of forms, including some combination of a) increases in fee-for-service payments, b) coverage for specific services, such as patient coaching, c) monthly lump payments, d) capitation, e) pay-for-performance for outcomes tied to the PCMH,  f) shared savings.

5. While dozens of pilots are underway, the largest is being sponsored by Blue Cross Blue Shield of Michigan.  This is likely to be eclipsed by a "Patient Aligned Care Team" initiative in all of the Veterans Administration's primary care clinics.

6. There are no data on what percentage of primary care physicians believe in the PCMH.  We also don't know how many plan to make the transition to one.  We also don't know if medical students will find the PCMH a compelling reason to go into primary care.

7. Last but not least, many past studies and current pilots are using only some of the PCMH principles, have inexact evaluation plans and many are not using a valid comparator.  It will be difficult to draw any consistent conclusions.

The DMCB will end with this closing quote by Dr. Berensen et al, which reminds it of what happened to the disease management industry.  It could not have said it better itself. Backers of the PCMH ignore this sage advice at their peril:

"The medical home model does have the potential to transform the way health care is delivered – but 'potential' is the key word here. The danger posed by the current enthusiasm for the concept is that it could lead to the adoption of unproven models on a wide scale nationwide before evaluations of existing pilots can show us what works in what situations, and what levels of reimbursement are needed to get providers to engage in all the new activities encompassed by the medical home model. This could lead to a failure to improve quality or save costs, and could result in a good idea being dismissed as ineffective before it has a chance to succeed. Whether we have the patience to nurture and recalibrate the medical home model as evidence comes in from evaluations before jumping to conclusions about its success or failure remains to be seen."


Paul said...

Good blog Jaan good points --You see for us the buyer of care we were just fed up with what the providers sell us and want a change covenant. So 47 of the fortune 100 and TRICARE asked the house of primary care for a set of principles we could all agree on they gave us the Joint principles of the PCMH. Now would you like care for yourself or your mother is what we asked them to give us principles. And it is what we have. The providers of comprehensive care were also are fed up with what we pay them for fed up with 19 to 31% administrative overhead, the hamster wheel, and also want to change the covenant so we agreed and we are !! I can tell you that in 5 to 10 years the practices that do not deliver much greater value will be out of business. The 47 fortune 100 companies (NOW many more) TRICARE and OPM we are shifting what we buy away from episodes of care towards managing a population care that is much more comprehensive, accessible, integrated, coordinated. Frankly if you have a better set of principles lay them down. If you think the principles can be tweaked tweak away happy to have them not all the same that is the very idea of multiple pilots testing different things all over the country -- Do not know why that bothers anyone. We are learning a huge amount from Michigan from the VA and hundreds of other places this is GOOD!!

In business we think continues improvement, lean, 6 sigma take waste and cost out --not absolutes not a question of does this PCMH work perfectly or not. You know what we pay now is absolute wasteful unethical garbage we expect at least a little better tomorrow. So we came to the house of primary care and said we would like to buy better and we now have an agreed on a set of principles we can buy against. We want to buy something better next year than this and for it to continue getting better leaving as it is not an option. Now that said the principles we the buyers asked the house of primary care for and they provide us are the joint principles of the PCMH on these we move ahead there are no other principles we all agree on that I am aware of unless you have some.

I do not get it OK so now what are you saying? Let the need for perfect get in the way of the journey to good. NO we have to stop buying episodes or care. So in our communities we are driving towards managing the population at the point of care in a PCMH.

We do not want to wait for a clear understand of what the perfect is to get stated. Rather we want providers to start getting better day after day and for us the buyer to focus like a laser on paying for that improvement when we see it. We are no longer waiting for perfect we have eaten PCMH it is good we are moving ahead. But, we hope the biggest learning that will happen is the deliver system will start to understand they will never ever be a perfect “PCMH”. Rather each day ask how can we do better, be leaner. be more efficient, deliver better service centered on our patients needs – continuous improvement .

So here is what is in our RFP what the plans have to sell us what our patients want this is in the request from OPM and many of the Fortune 100 right now today.

>24-7 clinician phone response
>Provide open scheduling.
>Provide care management and coordination by specially-trained team members.
>Use an EHR with decision support.
>Use CPOE for all orders, test tracking, and follow-up.
>Medication reconciliation for every visit.
>Prescription drug decision support.
>Implement e-prescribing.
>Pre-visit planning and after-visit follow-up for care management.
>Offer patient self-management support.
>Provide a visit summary to the patient following each visit.
>Maintain a summary-of-care record for patient transitions.
>Email consultations.
>Telephone consultations.
>The development of care plans.
>Performance outcome measures.

Bob Bowman said...

This was a piece that adds much - critique rather than blind focus on innovation. Three reasons why PCMH may not work.
1. Patients and their environments and various social determinants shape outcomes for significant portions of the US pop.
2. Primary care nurses are a key component as the largest primary care workforce at 270,000 with impact before, during, and after encounters and are likely to be short in supply and less experienced - due to low primary care spending and rapidly more complex jobs with less support.
3. Any primary care with more spending and more support that allows continuity to be preserved in personnel and professionals and practice is likely to as well as PCMH and better than a PCMH with less spending or more complex patients.