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PCMH: A Promise Unfulfilled?

Posted By Matthew P. Martin, Thursday, March 27, 2014

PCMH (Patient-centered medical home) initiatives are familiar to many of us. In fact, some have probably considered getting those four letters tattooed in large gothic style on some part of their bodies. Why is there so much support? Because medical homes promise so much.  In theory, the PCMH is a team-based model of primary care designed to improve quality, efficiency, and patients’ experiences. Considering the lack of quality and efficiency in our current health care system, such a model should be a godsend. Indeed, some of the most recent PCMH studies are promising.

For those of you unfamiliar with PCMH, read the
Joint Principles for a nice introduction. For a quick rundown see this video.

Now the question is: can the PCMH model deliver on its promises? According to a recent study published in the Journal of the American Medical Association, PCMH failed to lower service use (i.e., ambulatory, emergency, and hospital) or total costs and produced little quality improvement over three years. The results of the study have been summarized here, here, and here. This isn’t the first time researchers have raised a warning flag for PCMH. Another study by JAMA suggests that medical homes have higher per patient operating costs while another author of the American Journal of Managed Care warns that consumers, especially the rising generations, will not want medical home-style care.

What do we learn from this most recent study then? According to Thomas Schwenk, PCMH may be “best deployed in a more concentrated approach for patients with costly conditions and high use” like the chronically ill. And according to the Patient-Centered Primary Care Collaborative, the NCQA-recognized pilot practices did not go far enough in transforming care practice. For example, weekend and evening hours were rarely offered to patients and there were no financial incentives to control costs. Marci Nielsen, the PCPCC CEO, even wonders if these pilot practices had yet transformed to be true medical homes.

Here are some other lessons:

  1. Clinic managers need to know what patients need and want from their primary care service (e.g., expanded clinic hours, walk-in slots). Few if any of the pilot practices in the JAMA study received feedback on their patients' care utilization.
  2. All key features of the medical home should be measured (e.g., patient engagement, behavioral health integration, team-based care). Several of these features were not measured by the authors.
  3. We need longer, larger PCMH studies with better practice comparisons. This recent study was from 2008 to 2011, only three years. Also, the response rate for the “control” group was only 24% compared to 91% for the “intervention” group. 
  4. The PCMH model needs integrated behavioral health care. Recently, one working group developed principles for integrating behavioral health care into the PCMH. Whether PCMH evolves into a model for the chronically ill or stays more general and comprehensive, patients should have access to behavioral health services.

Is this recent study a nail in the coffin for medical homes everywhere? I don’t think so. Undoubtedly, it is true that proponents of PCMH have a tough row to hoe. They must convert all the enthusiasm and activity for medical homes into a sustainable, evidence-based model. They must also decide if this model is a “one-size fits all” or a disease- or population-specific model or something else entirely. This study seems more like a clarion call for a more refined PCMH model that is supported by bigger, better research.

Personally, I am optimistic. I believe in the progression of science, that research will help us identify those key PCMH features and processes that lead to the greatest outcomes. Such research will require more time, energy, and money to determine which patients benefit the most from a team-based, care management model.

But I am still left with a few nagging questions. How we will know if this entire “medical home” approach is the wrong direction? Is this style of medical care what patients want these days? There are a lot of urgent care clinics in my town and they seem awfully busy. Moreover, will we have the primary care workforce that we need to run medical homes? Even if research shows that medical homes are awesome, will there be anyone to run them? Although these questions are interesting and somewhat important, maybe the most important question right now is: does PCMH deliver on its promises?

 Matt Martin, PhD, LMFT is a licensed marriage and family therapist and current Director of Applied Psychosocial Medicine at the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He is current editor of both CFHA blogs. His research interests include integration of behavioral health services in primary care settings, behavioral science curriculum development, family-centered primary care, and self-awareness development in family medicine residents. Email:


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Barry J. Jacobs says...
Posted Friday, March 28, 2014
Twenty years ago (or more), Orson Welles did a television commercial in which he famously said, "We sell no wine before its time." If only that saying were true for the wildly hyped PCMH. This "wine" has been thrust at us as some life-prolonging elixir when it tastes like grape juice (if not vinegar). And who's guzzling this? Most of us, to be sure. Have we just convinced ourselves that we really have the good stuff? That's a question we don't ask ourselves enough. I'm not boasting is this hearty vintage until enough time has passed.
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Lisa Zak-Hunter says...
Posted Thursday, May 01, 2014
Sounds like a call for some good qualitative or community based participatory research to me! Often top-down approaches do not take into consideration population and community characteristics, demographics, culture etc. Working in a residency clinic where we have physician turn over every 3 years and patients may not consistently see their PCP, I'm interested what our PATIENTS want/need from us. Our model of care may be best implemented when we have community representatives and cultural brokers actively engaged with us in the transformation process.
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