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4 Reasons PCMH Principles Aren't Going Away

 |  By Philip Betbeze  
   March 07, 2014

A recent analysis finds lackluster results in both cost reduction and quality improvement from organizations that have achieved Patient-Centered Medical Home certification. Does that mean we need to go back to square one?

Have you heard the news? The patient-centered medical home model is a failure.

One takeaway from a recent analysis on the medical home is that for all its purported promise, the designation appears to be little more than window dressing for practices that achieve it.

The report, published in last week's JAMA, and covered well here by my colleague Cheryl Clark, compared quality, utilization, and costs of care delivered to about 120,000 patients in 32 Pennsylvania practices. About half of the patients were treated by physicians in PCMHs certified or recognized by the National Committee for Quality Assurance; the others were treated by physicians in traditional practices.

The conclusion? Physician practices designated as medical homes were no better at controlling costs than traditional practices and were better in only one of 11 quality measures evaluated.

But it would be wrong to dismiss the movement toward patient-centered care as ineffective based solely on the findings of the study.

The report found that compared with traditional practices, NCQA-certified PCMHs did no better at controlling costs than traditional practices. They also did not improve on traditional practices' performance on 10 of 11 quality measures evaluated, such as cholesterol testing and cervical cancer screening, or in avoiding emergency room visits of patients who could have been seen in an ambulatory setting. The only measure where some improvement was seen in the medical home groups was in nephropathy screening for kidney disease in patients with diabetes.

So, like other highly touted panaceas that have attempted to rein in runaway healthcare costs and address dubious quality only to fall far short, does the PCMH movement's hype far exceed its results?

Perhaps. In this limited sample size over three years, it appears so. But before we file the designation under "Bad Ideas," let's address what the report leaves out.

1. The sample size was too small.

Analyzing the cost and quality results from 120,000 people over three years is a big task, but perhaps it's not big enough. After all, this report analyzed only a small piece of the PCMH-designated universe in a very limited geographic area.

Other studies have come to strikingly different conclusions. This report by the Patient-Centered Primary Care Collaborative, admittedly an advocacy organization, cites several PCMH initiatives that have gone on for much longer than three years, and that have saved significant sums (see page 9) in costs, and have had marked positive effects on utilization, quality and outcomes.

Health plans and the government are big believers, and since they pay the freight of healthcare services, there's no sign they are doing anything but increasing their investment in the PCMH structure.

2. Certification is only one of the first steps.

The fact is that Patient-Centered Medical Home certification is far from a guarantee that an organization is taking the necessary steps to both improve quality and cut healthcare spending. What it does do is assure that they have the tools to better coordinate care, and that staff at a particular practice have been trained to serve as the center of care for their patients.

Whether those tools are used effectively isn't measured. Practices are still learning, and clinicians are still figuring out the best way for their organizations to achieve goals of good patient outcomes, and they're still staffing up or rearranging the type of work that the physician's assistants should do to improve outcomes.

This is not surprising. You can have all the technological links in the world, and you can be certified, but if your practitioners don't use those tools to better communicate and connect with patients and their services at other sites, its promise is stillborn. Indeed, these softer skills are harder to quantify, but critical to the work. And aren't evaluated in the drive to achieve certification.

3. Principles pass the common sense test.

The principles of patient-centered care are still relatively new, especially to patients. And they aren't used to it. Patients are used to being on their own for healthcare outcomes, and the fact that a patient navigator is following up with them on needed care is unfamiliar. Old habits are hard to break.

It's common sense that acting on the principles of the PCMH, not just fulfilling the requirements to get the designation, should reduce healthcare costs and improve quality. If the PCMH designation leads to patients, payers and employers holding practices accountable for outcomes, it has promise.

At this point, certification is only a means to an end—perhaps we're still in the early innings of healthcare transformation. Certification, again, means that the tools are in place. Now practices have to figure out how to use them most effectively.

So PCMH designation is a necessary, but not a sufficient contribution to value and quality improvements in healthcare.

Anyone who's tired of the physician's responsibility to their care ending at the threshold of the office door or with the payment of a fee-for-service-based bill would have to root for adoption of the PCMH. It passes the common sense test. Fee-for-service, clearly, does not.

4. You have to do it anyway.

Big business is a big believer in patient-centered care, and many large employers and their insurers or third party administrators are as well. They see patient-centered medical home certification as an important first step toward forcing healthcare to take responsibility for outcomes. And many of the new risk-bearing contracting structures that health plans and government payers are debuting now and in the near future require PCMH designation as table stakes.

Healthcare organizations are rapidly ramping up their investment in achieving the designation. Last September's HealthLeaders Media Intelligence Report on physician alignment shows that 52% of healthcare organizations achieved or are involved in achieving PCMH certification, up from just 39% in 2012, and 58% expect to do so within three years.

The Patient-Centered Primary Care Collaborative report says WellPoint predicts its PCMH program could reduce its projected medical costs in 2015 by up to 20% based on analysis of its current medical home projects. So it's investing heavily. So is United Healthcare, which predicts that its PCMH efforts will save twice as much as they cost.

So that leaves us to determine the impact of the recent report. Clearly, it does not show positive results during the time period it measures. It also shows that achieving a certification or designation does not guarantee your investment in the tools of the PCMH will pay off. But does that mean all the time and effort setting up patient-centered medical homes, which payers are increasingly incentivizing, is wasted?

Certainly not. What it will deliver for healthcare is still to be determined, but I'm willing to give the benefit of the doubt to any scheme that will incentivize physician practices and other healthcare organizations to effectively work together to drive value and good outcomes.

Many healthcare organizations that never used to work together on these things are now doing so. It's a huge step forward for an insular, silo-based industry that has really never had to take business risk on how well it does what it's supposed to do—help people get better.

If the option is ditching it in favor of returning to the fee-for-service patient volume game, you can count me out.

Philip Betbeze is the senior leadership editor at HealthLeaders.

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