Will the Real PCMH Please Stand Up?
Bruce Bagley, MD, FAAFP
The recent article by Friedburg et al in JAMA, calling into question the value of the PCMH model in terms of improving quality and saving money, has rekindled the discussion about the effectiveness of primary care redesign. At a time when there is good support for fortifying primary care coming from all quarters, we must once again have the conversation about whether it works or not. The RAND study was well done by well-respected researchers and therefore deserves a thoughtful analysis. The PCPCC, the Commonwealth Fund and others have commented on the details of the study design so let's focus on the central issue.
Over the years, we have struggled with the Patient Centered Medical Home as a brand both because of the words and the lack of clarity about the definition and its essential components. In marketing circles there is usually a brand strategy and a marketing plan around that strategy. The original Future of Family Medicine report, published in 2004, used the term "the new model of care" which begged for a symbol, a tag line, better definition and more clarity. Primary care and the discipline of family medicine missed the opportunity to create that image or brand and the result was the emergence of "advanced primary care," "patient centered health home" and "patient centered medical home" among others. The pediatric community had long used the term "medical home for children with special healthcare needs" but that was clearly too narrow for general use by primary care. As patient centered medical home began to emerge as the front runner in common parlance, detractors were quick to point out that the word medical was all about doctors, thereby excluding other providers and testing with patient focus groups showed more association with the concept of nursing home than robust, service oriented primary care. To their credit, the four primary care physician organizations (AAFP, AAP, ACP and AOA) published the Joint Principles for Patient Centered Medical Home in March of 2007. This document served as more of a vision statement for patient centered medical home than a road map for how to get there.
When payers became interested in providing incentives for primary care redesign, there was a need to have objective, measurable criteria for the PCMH and they needed a neutral third party to adjudicate whether practices really had changed or not. NCQA entered the fray with a set of relatively objective criteria along with a scoring and recognition system to fill that void. Without substantial alternatives, the NCQA rapidly became the market leader in the PCMH game and the result has been that the NCQA PCMH Standards currently provide the de facto definition for PCMH in the minds of many including the researchers at RAND.
We believe that the term "patient centered medical home" must signal a total redesign of primary care so that it is more service oriented for patients, more effective for better patient outcomes, more efficient for a better practice bottom line and more fun to go to work for all involved in this noble work of helping people with wellness, disease prevention and chronic illness management. If this sounds familiar it is simply "the Triple Aim plus one"…Better care for the individual, Better population health and Lower per capita cost of care. The plus one refers to high provider and staff satisfaction with the work that they do because they know it gets better results for patients.
The NCQA PCMH Standards provide a useful list of process measures for primary care practices but lack any real attention to measured outcomes, quality targets or cost saving strategies. So let's get back to the Pennsylvania primary care practices that received approximately $92,000 per physician over three years to "become recognized by NCQA as a PCMH." They accomplished what the incentive called for and along the way improved systems, office work flow and their organizational maturity. Nowhere in the plan design are there targets for quality or cost of care to qualify for the incentives. Let us be fair, the NCQA PCMH Standards have been extremely useful in moving practices along in change management and practice redesign by offering detailed guidance and objective assessment. There is more to the PCMH story…transparent, measureable patient oriented outcomes and assessment of the efficiency of the delivery of that high quality care! Both are needed if we are to truly determine "value" for patients.
Is the practice in which you toil a PCMH? Show me your numbers and we will see where you stack up. How do you compare with other similar practices on the common CMS or NQF clinical quality measures? What is your total cost of care calculated on a PMPM basis and detailed down to the individual NPI number? How have you really engaged patients in your redesign efforts and how are your service and satisfaction scores?
Will the Real PCMH Please Stand Up?