The Patient Centered Medical Home: Will This Horse Drink?

If you lead a horse to water, will it drink?  If it drinks, does that cause it to be a horse?  Who says being a horse is good? Do horses cure thirst?

Those were the silly Disease Management Care Blog questions prompted by a paper trail of articles and letters about the Patient Centered Medical Home (PCMH) that recently appeared in the Archives of Internal Medicine.  That being said, the series was a telling example of the assumptions underlying PCMH research and the lack of of buy-in from community-based physicians

To wit:

Primary Care Is Good: The first article was this October 2011 published research that retrospectively mined the Surveillance, Epidemiology and End-Result (SEER)-Medicare-linked database.  The authors found that for Medicare fee-for-service beneficiaries aged 67 to 85 years, more colorectal cancer screening, earlier cancer diagnosis and lower cancer mortality were all associated with an increased number of past primary care visits. While the study could not rule out the possibility that other factors were involved in the association between primary care and cancer screening (Katy Couric's campaign, for example, could have prompted patients to see their PCPs), this study indicated that that access to primary care is a good thing.

If Primary Care Is Good, So Is The Patient Centered Medical Home: The second article was this "Decisive Moment" editorial appearing in the same issue of the Archives, authored by Boston academics Asaf Bitton and Joseph Frolkis.  They reviewed the SEER article, which never even mentioned the PCMH.  That didn't stop the editorialists from bringing it up in an opening paragraph as an "innovative model of care delivery." The article then went on to describe the virtues of generic primary care and the need to increase PCPs in the physician workforce. It then saluted the PCMH as "offer[ing] promising early results [with] a pathway to weld some of the best incremental practice change initiatives onto a chassis of sustainable, term based care."

Who Says the PCMH Is So Good? The third was this Editor's Correspondence letter that appeared six months later in the March 26 2012 issue of the Archives. Arguing that many PCPs already provide medical home-like services, private practitioner Edward Volpintesta of Connecticut didn't share Drs. Bitton and Frolkis' "optimism" over the PCMH  He observed that 100% of any additional fees generated by the PCMH would have to go toward funding its excess costs and never go toward rewarding the physician.

We Say It's Good: Drs Bitton and Frolkis disagreed in a Editor's Correspondence reply. Depending on your definition of a medical home, they argued that most PCPs do not offer that kind of care and that their research shows that the added income from the PCMH can be considerable. 

While the article-editorial-correspondence virtual paper trail is a classic exercise in academic repartee filled with the usual medical jargon, tangential policy nostrums, assumptions and quoting the literature out of context, the real lesson here is that there is some real skepticism about the PCMH among otherwise seasoned primary care physicians. While the mainstream peer-reviewed medical journals have articles that are extrapolating the virtues of primary care onto the PCMH, docs like Dr. Volpintesta aren't necessarily buying it.

To the DMCB, this spells significant challenges for the dissemination of the medical home outside the academic community and their early adopter allies. 

Some mainstream doctors remain unconvinced.