Infrastructure and process euals the patient-centered medical home?

[Guest guest]

Infrastructure and process equals the patient-centered

medical home?

The September/October issue of Health Affairs has some great

articles. Bob Berenson from the Urban Institute and others describe the

landscape of the patient centered medical home, doing a very good job pointing

out positive as well as negative aspects.

[Health Affairs 27,

no. 5 (2008): 1219–1230; 10.1377/hlthaff.27.5.1219]

A minor fact in his article deserves special mention: 33%

of physicians in the US

practice alone or with one partner. 42% are in practices of five or

fewer.

I make special mention of this in light of an accompanying

article by Diane Rittenhouse et al:

Measuring The Medical Home Infrastructure

In Large Medical Groups: The largest of the large medical

groups have the highest levels of medical home infrastructure, but adoption is

slow.

[Health Affairs 27,

no. 5 (2008): 1246–1258; 10.1377/hlthaff.27.5.1246]

Take

a look at the image below. The clear implication and the conclusion to

which the authors come is that:

“Increased

practice size is positively and significantly associated with increased PCMH

infrastructure.”

Following the Rittenhouse logic and

given the momentum behind the current medical home bandwagon, we will see money

and benefits diverted to those practices that meet the PCMH infrastructure

goals at the expense of those that do not. The implication of this trend

is frightening: it will effectively write off 33% if not 42% of all practicing

physicians in the US.

As frightening as that conclusion

may be, consider the assumption that “PCMH infrastructure” will

move the US

from its “Worst in Show” position on population health outcomes

(not to mention outrageous health inflation and the millions and millions of

uninsured and underinsured Americans).

I ask you to consider the following:

1: The

Institute of Medicine’s (IOM’s) Crossing the Quality Chasm report

identified patient-centered care as one of six overlapping domains of clinical

care quality, along with safety, effectiveness, timeliness, efficiency, and

equity.

2:

The Picker Institute has delineated eight dimensions of patient-centered care:

(1) respect for the patient’s values, preferences, and expressed needs;

(2) information and education; (3) access to care; (4) emotional support to relieve

fear and anxiety; (5) involvement of family and friends; (6) continuity and

secure transition between health care settings; (7) physical comfort; and (8)

coordination of care.

3:

A 2007 Commonwealth Fund survey studied the effect on patients of having access

to an “enhanced” regular provider, which they called a “medical

home.” The patient survey used four indicators to measure the extent to

which adults have a medical home: (1) having a regular doctor or place of care;

(2) experiencing no difficulty contacting the provider by telephone; (3)

experiencing no difficulty getting care or medical advice in evenings or on

weekends; and (4) having physician office visits that are well organized and

run on time.

4:

The core elements of primary care emphasize first-contact care; responsibility

for patients over time; comprehensive care that meets or arranges for most of a

patient’s health care needs; and coordination of care across a patient’s

conditions, care providers, and settings. (World Health Organization, Alma Ata

meeting 1978)

(All

four are direct cut-and-paste from Berenson’s article)

How

did our esteemed colleagues come up with the current rubric of the PCC PCMH

with such an overwhelming emphasis on infrastructure and process? Where

is the evidence to support the assumption that disease excellence (essentially

single organ system care) results in population health improvement beyond the

narrow condition?

Medicare

spends the bulk of its resources on patients with five or more

conditions. Do we have evidence that a disease specific approach works

for individuals like this? The body of literature supporting the disease

approach for real patients with multiple conditions is thin, and some studies point

out that a focus on one condition comes at the expense of another.

{Lin

et al. The effects of enhanced depression treatment on diabetes self

care. ls of Family Medicine Vol 4, No 1. Jan/Feb 2006}

Starfield

and others have published reams of articles demonstrating the link between

effective primary care and the outcomes we so desperately desire.

Excellent

single or even several-condition disease management does not equal excellent

primary care.

Organizations

are able to invest in IT systems and hire process consultants so that they can

win at the game of PCMH recognition. Some residency directors mentioned

to me the other day that they self-scored at the highest level on the current

PCC PCMH tool due to their infrastructure. This too boggles the mind as

one considers the probability of a residency clinic meeting the criteria noted

in the four definitions above. If a chaotic practice with extremely low

continuity and no data on whether their patients are really having their needs

met can score at the highest level on the current tool, one must question the

validity of the tool.

Aside

from diverting yet another stream of dollars to application fees and consultants,

one wonders if such box checking and screen-shots will lead to any actual

improvement in patient care.

Berenson

points out that a number of the primary care physicians he and his team

interviewed are skeptical of the current rubric found in the PCMH. That

skepticism appears justified.

We

must each and collectively keep our focus on those efforts that clearly and demonstrably

improve patient outcome and experience of care.

The

elements of the Ideal Medical Practice project are founded on the four pillars

of Starfield’s work (the WHO criteria noted in #4 above). These

improvements have an evidence base to support them. These elements can be

measured, and we have shown that SOLO AND SMALL PRACTICES CAN DO THIS

WORK! We must not be written off.

We

must individually and collectively call out the error in hurried pursuit of an unproven

tool. Improving patient care and population care is our work. We

can do this, but we must work hard not to be distracted by expediency dressed

up as improvement.

Gordon