“I Have a Hunch”

January/February 2014 Vol 7, No 1 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief
American Health & Drug Benefits
Founding Dean
Jefferson College of Population Health
Philadelphia, PA
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Like many persons who are concerned about the future of our healthcare delivery system, I have been carefully following the evolving literature and evidence on the patient-centered medical home (PCMH). I would therefore like to share with you a “hunch” I have about the future of PCMHs, with a special emphasis on an assessment of the current evidence about their effectiveness and long-term implications.

Alexander and colleagues assessed the policy context of PCMHs from the perspective of primary care providers.1 Let us begin by defining our terms. The PCMH is described by joint principles agreed upon by several professional societies. In essence, these include (1) a personal physician, (2) a physician-directed medical practice, (3) whole person orientation, (4) coordinated care, (5) an emphasis on quality and safety, (6) improved access, and (7) some changes in the payment system.

It is true, say Alexander and colleagues, that medical home models vary greatly in their practice and structure, “but their success is assumed to rest fundamentally on the ability to focus the work of a defined team on the needs of a patient or family, recruiting social services, specialty medical services, and patient capabilities to solve problems and coordinate care.”1

Through qualitative, semistructured, in-person interviews with key representatives of physician organizations and multiple primary care practices that were pursuing the creation of a PCMH, Alexander and his colleagues come to a sobering conclusion.

In essence, they found that “providers’ motivation to embrace the PCMH and their level of confidence regarding the results of such change are greatly influenced by their perception of the external environment and the control they believe they have over this environment.”1 More simply, Alexander and colleagues found that to turn a typical small primary care practice into a PCMH-designated center requires truly transformational change and a considerable amount of costly resources and organizational support that are not currently readily available.1 What I took away from the analysis by Alexander and colleagues is that it may be impossible to help providers recognize that unnecessary testing is a cost burden to the healthcare system rather than an income stream, without some kind of intervention from a large organization, such as a hospital-based integrated delivery system, managed care plan, or similar entities.

A later study by Fifield and colleagues added to my hunch that this transformation will not be easily or readily achievable.2 In their randomized controlled trial, Fifield and her team found that, regardless of size, “practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.”2 In my assessment, given the current environment, we could rationally expect that such change would come quite slowly to the average primary care practice. Fifield and her colleagues had embedded personnel at the practice sites they studied for months, to facilitate the transition to a PCMH,2 knowing that physicians have little direct experience in instituting patient self-management programs and performance reporting and improvement scorecards on their own.

Finally, in a systemic review of the PCMH, Jackson and his colleagues concluded that “the PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes.”3 So there you have it. The way I see it, and based on my review of the evidence, there is much more to this PCMH transformation than the average practice could essentially handle on its own at this time.

From a broader policy perspective, this means that integrated delivery systems, seeking to pivot from filling beds to caring for populations, are going to be woefully unprepared for this transition if they rely too heavily on a strategy of building National Committee for Quality Assurance (NCQA)-certified PCMH structures.

Another hunch I have is that most well-trained, well-meaning, hardworking primary care physicians have no “on the ground” sense of what many of the healthcare reform–associated changes will truly mean. Jackson and his team concluded their review by noting that although “implementing the PCMH principles is something to be considered by organizations seeking to enhance patient experience and quality of care, no menu is yet available for specific actions that are most likely to enhance benefits to patients, staff, and organizations.”3

Well, I do have another hunch: if no “menu” is yet available, how can we choose a particular meal? If randomized controlled trials on PCMH implementation do not specifically identify the components of this much-­needed menu, what are practices supposed to do?

We have not seen the end, or maybe even the beginning, of the PCMH movement. We have missed the central tenet—without physician leadership and physician commitment to organizational change (2 arenas where most clinicians have little formal training), PCMHs are bound to fail. And this, of course, calls into question the greater strategy of accountability and population-based medicine.

The drive to create accountable care organizations has obscured our vision at the ground level. It is my hunch that the PCMH, as the building block of an accountable system, is truly where the core challenge lies. Even as multiple specialty societies embrace the PCMH nomenclature, and as NCQA provides us with a greater number of operational measures, we are a long way from having the leadership skills and organizational understanding that clinicians will need to effectively implement this core strategy for reform.

References
  1. Alexander JA, Cohen GR, Wise CG, Green LA. The policy context of patient-centered medical homes: perspectives of primary care providers. J Gen Intern Med. 2013;28:147-153.
  2. Fifield J, Forrest DD, Martin-Peele M, et al. A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices. J Gen Intern Med. 2013;28:770-777.
  3. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158:169-178.
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