A PCMH Check Up

The Patient–Centered Primary Care Collaborative just published their 2015 report reviewing the annual evidence of Patient Centered Medical Homes (PCMH’s) from September 2013 to November 2014 called The Patient-Centered Medical Home’s Impact on Cost and Quality. Their major finding is that there is more evidence that PCMH’s are helping with both cost and utilization. The study examined 14 peer reviewed studies, 7 state studies and 7 industry studies all done in the past year.

To document the growth and outcomes of the PCMHs, The Patient –Centered Primary Care Collaborative produced an interactive map that focuses on both PCMH and other primary care innovations around the country.

An almost palpable sigh of relief can be read in the study, since the overall positive gist countered a well referenced 2014 JAMA study (included in their report) that is still getting much attention. The JAMA study concluded that the medical home pilot initiative it examined:

“…was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.”

But perhaps the larger question is how to analyze a health care strategy that is future oriented. The data has to follow the innovation and it would be unfair to expect too much in the beginning. Furthermore the innovation is occurring over an uneven economic landscape where some programs are better funded than others. This filters, for example, the reading of one JAMA study which examined the PCMH model at LAC+USC , a primary care safety-net teaching clinic in Los Angeles. That study concludes:

“Although the absolute improvements in satisfaction with access to care and overall care were large, the clinical significance is uncertain.  Specifically, it is unclear whether these improvements will be wide-ranging enough to entice patients to remain within our system as safety-net patients acquire health insurance as part of national health care reform and have choices about where they seek care. Thus, although we are encouraged by the improvements, we remain uncertain whether they will have a meaningful long-term impact. “

What is clear is that the PCMH model is proliferating very quickly, which is why at Doctors Council we believe that at this early stage of development the focus must remain on the democratization of the transition. By this, we mean the inclusiveness, input and involvement of the front line clinicians and patients. In short the community, the patients and the front line providers must be involved in a meaningful way. For us this is a worthy end in itself and central to the transformation of the U.S health care system. While we must follow the evidence to achieve the best health outcomes, the democratic/inclusiveness process itself is an outcome that cannot be lost in the mix.

In the literature the question of “physician buy in” is a common stand in to discuss front line doctor involvement in the process. A study in the Annals of Family Medicine for example is titled “Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home.”

Not surprisingly the paper concludes that “Novel findings of this study are that practice personnel strongly desired formalized solicitation of their input, access to leaders, and acknowledgement of how their input was or was not used.” And that “Participants in our study articulated the need for organizational culture that promotes an open exchange of ideas, shared creativity, overlapping but clear roles and responsibilities, and system-wide incremental change.”

Perhaps part of the problem is that “buy-in” is too often seen as a strategy and campaign in which the doctors are seen as the variables which must be manipulated to the proper ends. We take a different approach. We view the doctors and the patients as people that must be brought into the process with all the messiness that real power sharing involves.