Skip to main content.

Medical Homes Part 1: The Reality vs. The Hype

Medical Homes Part 1: The Reality vs. The Hype

Picture of R. Jan Gurley
Medical workers transfer patient to surgical table .
Image by MilitaryHealth via Flickr

Patient-Centered Primary Care Medical Homes (PCMHs) are all the rage. A frequently-touted part of the Affordable Care Act (ACA), they have received literally hundreds of millions of dollars in federal incentive and demonstration-project funding. They've been around for decades. In fact, the more you know about the intention behind the creation of a primary care Patient-Centered Medical Home (PCMH), the more you want to ask, "Well, of course - how could that not be a good idea?"

But is it?

Creating a medical home means building and using an integrated approach to health care where each piece of care is not treated separately and does not take place in isolation – nor is it all billed separately. Health care, communication, co-ordination, complications, follow-up and payment are all part of one system led by primary care.

See Also: Capturing a historic moment: Obamacare in California

PCMH is often reported as having started in 1964 by pediatricians, in order to improve the kind of fragmented, episodic and uncoordinated care that special needs children received at the time. The idea was that the primary care doctor (a pediatrician) was the "home" for all health care, and that the patient's family, and a care coordinator, were key members of a team.

While generally acknowledged to be an improvement for families then -- numerous opinion and consensus/expert panel papers exist -- it is surprisingly hard to find any randomized comparison data to support their efficacy. Despite this, PCMHs seem to inspire some of the most vaguely worded and glowing descriptions ever applied to a federally-funded regulatory initiative.  Check out this polished video from one of the Medical Home accreditation organizations. You'll see retro-Marcus-Welby hype, followed by person after person struggling to explain exactly what a Medical Home is. Even the most technocratic PCMH document will often begin explaining a Medical Home as "not a place, but a model" of care. "It's an ideal." Or, "it's a concept."

If you step back a bit, however, this revealing set of phrases presents a large number of uncomfortable questions, especially when vast amounts of health care dollars are at stake. Such as, if you're trying to change your primary care practice into a PCMH, how do you define a "concept of care"? Or, if you're a funder, how exactly do you pay someone more or less money based on whether they're following the "concept" or not?

Similarly, if "team-based care" is a huge part of the concept behind a PCMH, who will decide if a collection of people is actually a team or not? After all, an autocratic doctor (or any other uncooperative health care provider) plunked into a mandated "team" of other providers will likely remain just that -- uncollaborative. And finally, when it comes to patients, does the same health care "concept" achieve the same outcomes for each unique person?

In an effort to define the undefinable, a complex number of criteria have been created. Just check out the multi-faceted array of "voluntary" PCMH certification criteria that currently exist, such as from the National Committee for Quality Assurance, the Accreditation Association for Ambulatory Health Care and The Commonwealth Fund. Which criteria is better? Easier to certify? Or more effective?

Even a cursory glance at our current definition shows that the Medical Home idea has become far broader and more complex than that original approach. More modern health care strategies, like managing chronic conditions through disease registries and using Health Information Exchanges (HIEs) and Electronic Health Records (EHRs), are now central to PCMHs. There are also clearly conflicting criteria, such as the twin goals that patients always have ready access to their assigned primary care provider (empanelment), and that patients receive their care through specified teams of non-physicians (coordination).

There’s also an assumption that PCMHs are right for every patient, even those with more minor medical problems. In general, the ability to just make your own appointment with a dermatologist or orthopedist goes away. You need to go through primary care first. Even for something as serious as a new cancer diagnosis, that care is supposed to be launched and monitored through primary care.

Additionally, a striking issue when looking over the criteria for PCMH certification is the fact that surprisingly few requirements make a clinic more "patient-centered." Engaged leadership? Use of electronic health systems? That is what patients care about, more than anything else? If it is not proven that this criteria actually makes care more “patient center,” is the title of this initiative more about clever marketing? Afterall, who in health care wants to stand up and say they're opposed to being "patient-centered"?

Despite these issues, PCMHs are proliferating rapidly. The Alliance for Health Reform's 2013 book Covering Health Issues: A Sourcebook for Journalists, lists on page 53 the institutions and initiatives involved in documenting PCMH status – a dizzying number of agencies with their hand in the pot. With, as of May 2013, over 27,500 clinicians and 5,700 sites PCMH certified, certifying PCMH status is no longer a simple Do-It-Yourself process for clinics, but a booming nationwide industry.

But all this time and effort to make things "patient centered" has to be worth something, right?  Or is it just bad bureaucracy taking over another part of health care? Bad bureaucracy in health care isn't just annoying. Estimates are that it eats up one third of our health care budget or as much money as it would take to care for all the uninsured. PCMHs stand to create more. As one example, between 2010 and 2012, New York's state Medicaid program spent an estimated $398,947,964 taxpayer dollars (which includes a $250 million lump sum payment to hospitals and training centers) - from money designated for the health care of New York's poorest, and often most medically fragile and disabled patients - to implement this certification bureaucracy.

In my next post, Medical Homes: Part II, The Depressing Data, I will round up and summarize for you what the investment of millions of dollars has actually produced. Afterwards, in Medical Homes: Part III, The True Cost, I’ll examine how the certification and implementation process takes time and resources away from patient care.

Related Stories:

Will the Affordable Care Act help women who are divorced?

Medicaid gap leaves Obamacare haves and have-nots

Untangling Obamacare: The affordability puzzle

Image by MilitaryHealth via Flickr

Comments

Picture of <span class="username">Guest (not verified)</span>

Great article,,,looking forward to part II - I think the theme to this article is the states and governments really don't know what they are looking for in a PCMH, but I do believe this model would work if the ancillary staff supported the physicians and patients properly. I feel that most practice staff members don't know how to properly coordinate care, see it through and follow up.

Picture of <span class="username">Guest (not verified)</span>

Thanks for the comments and your insights. Improving coordination and care is a complex, team process. I'll be interested to hear your thoughts about the next pieces too!

Picture of <span class="username">Guest (not verified)</span>

Health and health status change across the life course. To be healthy relies on not only medical but physical, oral, and emotional health. Health needs change as a person passes from childhood through adulthood to end of life. Patient-centered medical homes will always fall short. Interprofessional health homes that emphasize wellness for a person or family have a chance at success.

Picture of <span class="username">Guest (not verified)</span>

Thanks for sharing your thoughts. Wellness is indeed a lifelong endeavor. I hope you will check out the next two posts in this series to find out more about the data-efficacy (or lack thereof) and costs of this latest initiative.

Picture of <span class="username">Guest (not verified)</span>

Jan,

Interesting series of articles. I was curious if, in your review of the research literature on PCMH, if you have come across anything pertaining to the mediating role of physician-patient communications relative to outcomes, cost or patient experience/satisfaction?

My research suggests that the majority of physicians in general continue to employ a distinctly bio-medical approach vs. the patient-centered, psycho-social approach called for by the IOM in Crossing the Quality Chasm the ACA, etc. Here's an example from my blog Mind The Gap

- Satisfaction With Provider Communication In Recent Study Is Lower In Patient Center-Medical Homes (PCMH) Than Non-PCMH http://wp.me/p3Dxul-18d

- Patient-Centered Medical Homes Need To Become More “Patient-Centered” http://wp.me/p3Dxul-SX

I am convinced that the first generation of PCMH pilots, many of which you have addressed in your series, have paid more attention to building out the infrastructure needed to get accredited rather than pay attention to the aspect of patient-centeredness, beginning with communication, that has been shown in the literature to make a difference in outcomes, safety, cost reduction and satisfaction.

I look forward to your feedback and the rest of your series.

Leave A Comment

Announcements

Instability and the prospect of sharp premium increases are roiling health exchanges across the country. This webinar will put the latest news developments in context, discuss the ways in which GOP plans may impact the health exchange markets, and offer advice for reporters covering this story in their region. Sign up here!

CONNECT WITH THE COMMUNITY

Member Activities

Kathleen McGrory has shared a fellowship project

Read it.

Giles Bruce has shared a fellowship project

Read it.

jorge botello's profile has been updated

Connect with jorge botello

Anna Romano has shared a blog post

Read it.

Erica Montes's profile has been updated

Connect with Erica Montes
More Member Activities

Follow Us

Facebook


Twitter

CHJ Icon
ReportingHealth