Recent research that casts a pall on the cost and quality effectiveness of the patient-centered medical home is far from the final word on what patients—especially older, expensive ones—say they want from their physicians.
A few weeks ago I wrote about the compelling research published in the Journal of the American Medical Association that showed no effect on healthcare costs from the patient-centered medical home designation and little improvement in quality of care.
The results reported by JAMA are more than a little concerning for people who theorize that team-based, well-coordinated care is more efficient and less costly, and ultimately benefits patients' health.
They're especially concerning for physician practices that feel they need to make the substantial investment required to achieve PCMH designation. Increasingly, that designation—particularly the top achievement, Level III—is being required of primary care practices in order to attain incentives from payers and other healthcare partners.
Though the research reaches troubling conclusions in both ROI and improvement in quality, it certainly does not end the debate or the push for PCMH designation from payers and others.
In an attempt to find as neutral a source as I could regarding this research and the uncertain future of the PCMH, I spoke recently with Christopher Langston, PhD, program director for the John A. Hartford Foundation, a nonprofit based in New York that attempts to improve the health of older adults.
The foundation provides grants for research and education in geriatric medicine, nursing, and social work. It conducted a recent poll of older Americans who overwhelmingly supported the ideas embodied in the PCMH construct, and he also found the results from the JAMA article "troubling."
"I think highly of the people who conducted this study," he says. "They didn't do that study thinking it wasn't going to work."
For that matter, no one undertakes the substantial investment in the tools and human capital necessary to achieve PCMH designation thinking it's not going to work either. But the results speak for themselves. Or do they?
Not the Final Word
Langston cautions that while the study measured the before and after performance of 32 early-adopting practices over a three-year period between Jun 1, 2008 and May 31, 2011, it is not the final word on the effectiveness of the medical home construct, especially as far as patient preferences are concerned.
While the JAMA study's findings show little progress toward the goals of the PCMH, its results don't necessarily reveal the true picture of the benefits the medical home can deliver in both cost and quality spectrums, says Langston. In other words, the jury is still out, in his mind.
"In the methodology, only half the participating practices actually reached Level III [the highest PCMH designation]—only 16–so are we really evaluating the patient-centered medical home?" he asks. "The medical home lays out the walls and ceiling but doesn't decorate the room."
What distinguishes the failures from the successes in primary care, he says, is going to another level of specificity of the elements in the PCMH that are intended to help patients better access the care they need and keep themselves healthier.
Langston says an example of what he means is the IMPACT intervention model of evidence-based depression care that the Hartford Foundation trialed almost 10 years ago. IMPACT uses a lot of the structural elements of the medical home: a patient registry, structured assessment tools, a nurse to work the registry, and a particular depression scale that is reapplied to patients later in their care to understand whether they're getting better or not.
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"Like with the PCMH, you have to know how to use it and what the rules are. For example, if someone doesn't improve in four weeks, we'll change their dose," he says, to illustrate the specificity of follow up care necessary to fully take advantage of the medical home's capabilities. "That's the kind of 'furniture' that I don't think the PCMH provides overall. The structure needs to be filled in in a fairly systematic and thoughtful way."
Help Needed
According to a 2002 study in JAMA, IMPACT more than doubles the effectiveness of depression treatment for older adults in primary care settings. And patients receiving this type of care had lower average costs for their medical care—about $3,300 less even after factoring in the extra cost of IMPACT care—than patients receiving usual care.
The lesson, according to Langston: Don't evaluate things before they're ready. Second, even if every practice had been at Level III, it really matters what the clinical content is, and most practices are not good enough inventing that on their own; they need help.
If they don't get that help, and get bogged down in investments, disagreements about division of labor, and other organizational struggles, the investment in the patient centered medical home is not money well spent. The recent JAMA study, he says, has no real way of knowing the fidelity with which the practices are implementing the model.
"What they knew is what the practice said about whether they've gotten better about referring to other sources, such as for diabetes," he says. "There's no measurement of whether that really happened."
Also, such a study would be more valuable with a segmented population, he adds.
"They tried, but they only had commercial patients, they didn't have the full range," he says. "For example, they don't have people in the last years of life. It's harder to show benefit unless they had the full range and complexity of patients."
He adds that in the case of the PCMH, misimplementation can be worse than nonimplementation.
'Worst of Both Worlds'
"This is a case where half a loaf is not better than no loaf," Langston says. "If you hire someone but they don't know how to use the rules right, you have that added expense, but you don't get the return on investment. It's the worst of both worlds because you have the added expense but you don't achieve outcomes. What really matters is measuring outcomes, tracking them, and rules about what you do when someone doesn't get better," he says.
Langston believes that the despite the headline findings in the research study, the PCMH is far from discredited. In fact, its many attributes are highly sought after by older adults, who like the concept of team-based care. He cites the Hartford Foundation's recently released poll results as evidence.
Among the top findings, he notes, is that only 27% said they currently receive well-coordinated care. Of that group, some 83% said that team care has improved their health.
And among older adults who are not currently receiving this type of care, 61% said they believe team-based care would improve their health and 73% want this type of care. The research was conducted nationwide over four days in January and February, and surveyed 1,107 adults 65 and older.
"Not very many older people are getting the elements to the PCMH," says Langston. "Those who do think it's very helpful to improving their health, which we think is a pretty high standard for people to endorse. Even people who weren't getting it thought these elements had a potential to benefit their health."
Of course, it's a poll, not a peer-reviewed study, but as the most expensive cohort for healthcare spending, shouldn't policymakers—and physicians, for that matter, listen to people over 65 about what they want from their healthcare too?
Philip Betbeze is the senior leadership editor at HealthLeaders.