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
in our current health care system, such a model should be a godsend. Indeed, some of the
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
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,
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
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
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:
- 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.
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.
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.
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
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: firstname.lastname@example.org|