Wednesday, February 26, 2014

The "Patient Centered Medical Home": A Pig in a Poke

Some of my readers might find this post a bit dull, but as a primary care doctor I find this information fascinating.  It also took me an hour and a half to write it, so please, read on...

Some of you might be familiar with the concept of a "Patient Centered Medical Home," or PCMH.  This is something that was trotted out around 2006, and I'm both embarrassed and angered to admit that it was my own specialty organization, the American College of Physicians, that instigated it.  Now, in all fairness to the ACP, I think their intentions were good.  They saw that the cost of care in this country was rising in an unsustainable manner.  They saw that fewer and fewer doctors were entering primary care, frustrated with the low reimbursement and high paperwork demands.  They wanted a way to improve the primary care system.  But, you know what they say about good intentions. They pave the road to hell.

The American Association of Family Physicians jumped on the bandwagon the next year...and then in 2008 the bureaucrats joined the party.  A veritable alphabet soup of acronyms (The NCQA, JCHAO, AAAHC) began creating guidelines, accreditations, and payment schemes.  The Affordable Care Act specifically included provisions for PCMHs.

So, what's so great about a PCMH?  Here is the general idea, taken from the 2007 guidelines developed by the ACP and AAFP:

  • Personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care."
  • Physician directed medical practice: "the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients."
  • Whole person orientation: "the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals."
  • Care is coordinated and/or integrated: Care is coordinated and/or integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology and exchanges, ensuring patients receive culturally and linguistically appropriate care.[9]
  • Quality and safety
    • Partnerships between the patient, physicians and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care
    • Guide decision making based on evidence based medicine and with the use of decision-support tools
    • Physician’s voluntary engagement in performance measurements to continuously gauge quality improvement
    • Patients are involved in decision making and provide feedback to determine if their expectations are met
    • Utilization of informational technology to ensure optimum patient care, performance measurement, patient education, and enhanced communication
    • At the practice level, patients and their families participate in quality improvement activities.[9]
  • Enhanced access to care is available through open scheduling and extended hours and new options for.[9][24]
  • Payment must "appropriately recognize the added value provided to patients who have a patient-centered medical home."
    • Payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit
    • Services involved with coordination of care should be paid for
    • It should support measurement of quality and efficiency with the use and adoption of health information technology.[25]
    • Enhanced communication should be supported
    • It should value the time physicians spend using technology for the monitoring of clinical data
    • Payments for care management services should not result in deduction in payments for face-to-face service
    • Payment "should recognize case mix differences in the patient population being treated within the practice"
    • It should allow physicians to share in the savings from reduced hospitalizations
    • It should allow for additional compensation for achieving measurable and continuous quality improvements

When I first read about this, I kind of thought, "OK?  How is this different than what I do now?"  The answer was that it really wasn't.  But if I wanted to be considered an Official PCMH, I would have to be accredited.  And in order to be accredited, I'd need to meet certain benchmarks, which basically are 10 standards that must be met:

ELEMENT 1A—Access and communication processes
The practice has written processes for scheduling appointments and communicating with patients.
ELEMENT 1B—Access and communication results
The practice has data showing that it meets the standards in element 1A for scheduling and communicating with patients.
ELEMENT 2D—Organizing clinical data
The practice uses electronic or paper-based charting tools to organize and document clinical information.
ELEMENT 2E—Identifying important conditions
The practice uses an electronic or paper-based system to identify the following in the practice’s patient population:
  • Most frequently seen diagnoses
  • Most important risk factors
  • Three clinically important conditions
ELEMENT 3A—Guidelines for important conditions
The practice must implement evidence-based guidelines for the three identified clinically important conditions.
ELEMENT 4B—Self management support
The practice works to facilitate self-management of care for patients with one of the three clinically important conditions.
ELEMENT 6A—Test tracking and follow-up
The practice works to improve effectiveness of care by managing the timely receipt of information on all tests and results.
ELEMENT 7A—Referral tracking
The practice seeks to improve effectiveness, timeliness and coordination of care by following through on critical consultations with other practitioners.
ELEMENT 8A—Measures of performance
The practice measures or receives performance data by physician or across the practice regarding:
  • Clinical process
  • Clinical outcomes
  • Service data
  • Patient safety
ELEMENT 8C—Reporting to physicians
The practice reports on its performance on the factors in Elements 8A.

Read these carefully, please, and tell me what you think might be wrong with these standards.  Well, aside from the bureaucratic gobbledygook, the vast majority of these standards only have to do with tracking data.  Elements 1B, 2D, 2E, 8A and 8C are about data tracking.  So 5 of the 10 "must have" standards for the Patient Centered Medical Home have nothing at all to do with patients.  They are just about data collection.

You can't just say that you're a patient centered medical home.  You have to apply to one of the 3 certifying agencies and do a ton of applications and undergo an on site audit, which can cost up to $8000.  You can't just say that you track referrals and coordinate care with specialists.  You have to hire a nurse case manage to do this or designate a staff member.  You can't just track data with a paper and pencil or Excel spreadsheet.  You have to purchase an EMR with special registry capabilities.

Therefore, the cost of becoming a PCMH is quite high.   Factoring in cost of the technology and electronic medical records along with the additional staff needed to be hired to perform "care coordination,"  it can be anywhere from $100,000 to $500,000 per physician.

Now, something that is so heavily promoted, so supported by every major medical organization, so expensive, must be good, right?  There must be a ton of data to support the effectiveness of the PCMH and its ability to improve health outcomes and reduce costs to the average American.  That would be the logical thought.  However, logic often plays no role in public policy.  In fact, there is very little evidence to support any of this.  A study released last year concluded that:
This evidence indicates some favorable effects on all three triple aim outcomes, a few unfavorable effects on costs, and mostly inconclusive results (because of insufficient sample sizes to detect effects that exist or uncertain statistical significance of results because analyses did not account for clustering of patients within practices).

This is in direct conflict to this report, which extols the virtues and success of the PCMH model.  Of course, that report is put out by the Patient Centered Primary Care Collaborative, which is an advocacy group whose stated agenda is to promote the PCMH model.  So, no conflict of interest there, right?  Plus, this report is based almost entirely on industry data from insurance companies, so again, pretty biased.

The fact is that there is a serious dearth of evidence to support the PCMH model.  Most of the "evidence" comes from extrapolating the better health outcomes from other countries that rely more on primary care rather that the fragmented specialist system we have here.  But that's comparing apples and oranges.

A great study was published this week in JAMA called, "Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization and Cost of Care."  The study evaluated 32 primary care practices in Pennsylvania who voluntarily became PCMHs.  The data analysis compared their costs and quality outcomes to 29 non-PCMH practices.  It also compared their performance from before they became PCMHs to after.  Three years of data were analyzed.  The results were pathetic, to say the least.  Out of 11 quality measures, only one showed improvement in the PCMH group.  One.  Hospitalizations did not decrease.  Emergency room visits increased.  Specialist visits increased.  Total cost of care increased.   I mean, these results are bad.  Really bad.  Couldn't really be much worse.  In typical understated academic fashion, the study concludes, "These findings suggest that medical home interventions may need further refinement."

You think?

I'm not particularly surprised by results, and most of my colleagues aren't, either.  We haven't been buying what the PCMH is selling.  When you start concentrating on data collection instead of patient care, it should not be a surprise that outcomes are worse.  When you hire additional people to "coordinate care" instead of letting the patient's doctor do it, continuity suffers and care quality goes down.  When you are dazzled by e-technology and start letting electronic charts be the focus point of a visit instead of the patient in front of you, patient care suffers.

This is not rocket science, people.  Unfortunately, this is what happens when policy is put before practice.