Kevin Grumbach, MD Department of Family & Community Medicine
Patient Centered Medical Home (PCMH) is not a pill Kevin Grumbach 2013
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Invited Commentary The Patient-Centered Medical Home Is Not a Pill Implications for Evaluating Primary Care Reforms Kevin Grumbach, MD The patient-centered medical home (PCMH) is not a pill. It would be much easier to evaluate this primary care reform if it were. In this issue of JAMA Internal Medicine, Rosenthal et al 1 report their evaluation of the pilot program of a patient- centered medical home model of primary care at 5 practices supported by a consortium of 3 Rhode Island health insur- ance plans. Findings on patient outcomes were mixed. Dur- ing the 2-year postinterven- tion period, patients in the pilot practices had 11.6% fewer emergency depart- ment visits that were potentially avoidable compared with matched control patients in other practices, with a nonsignifi- cant decrease of 5.2% in total emergency department visits. A similar trend was observed for hospital admissions, with non- significant decreases of 15.1% for potentially avoidable admis- sions and 2.9% for total admissions. No significant differ- ences were found in diabetes care and cancer screening, although colon cancer screening rates increased by a sizable but not significant 37% during the postintervention period. Primary care advocates may conclude from this study that a significant reduction in potentially avoidable emergency de- partment visits and strong trends in favorable outcomes for avoidable hospitalizations and colon cancer screening add to the evidence that supports redesigning primary care. Skep- tics may conclude that the lack of significant differences in quality measures and overall use is evidence of the lack of ef- fectiveness. Thus, it is important to place in context evalua- tions of the patient-centered home model. If the patient-centered medical home were a pharmaceu- tical product, research to justify Food and Drug Administra- tion approval would need to demonstrate safety and thera- peutic benefit. By this standard, the substantial efficacy of the patient-centered medical home for colon cancer screening and the lack of reporting of any patients in the 5 practices who had bad care experiences would support approving the patient- centered medical home as an efficacious and safe product. This conclusion would be bolstered by a recently published sys- tematic review of patient-centered medical home evalua- tions that found “a small positive effect on patient experi- ences and small to moderate positive effects on the delivery of preventive care services.” 2(p175) As is the case for new medi- cations, expectations that health plans pay for practice rede- sign would follow soon after regulatory approval. No such luck for the patient-centered medical home. It is not enough for it to be nonharmful and to demonstrate some degree of efficacy. In many quarters, the patient-centered medi- cal home is judged on whether it is a “home run” for the ills of the US health system 3 —specifically, a 3-run homer achieving the triple aims of better health, better patient experience, and lower costs. Reducing overall costs is a paramount aim for the Centers for Medicare and Medicare Services and other pay- ers. The ability to generalize payment reform for primary care beyond the current pilot and demonstration projects largely depends on the ability of the Centers for Medicare and Medi- care Services to convince the actuaries at the Office of Man- agement and Budget that the reforms cost the federal govern- ment no more—and ideally less—than would otherwise have been spent. Clamor for the reforms that are part of a patient-centered medical home reflects the broad recognition that health sys- tems do not function effectively or efficiently without a strong foundation of primary care and alarm that this foundation is crumbling in the United States. Revitalizing primary care re- quires an infusion of resources and changes to care delivery. 4 Of course, primary care is deprived of resources and under- valued and consumes only approximately 6% of total health care spending in the United States. So, it is legitimate to ques- tion the reasonableness of making an investment in the revi- talization and retooling of primary care contingent on promptly “bending the cost curve” for the remaining 94% of health care spending. Those who evaluate patient-centered medical home in- terventions contend with finding sensible methods for study- ing complex changes in health care delivery in the dynamic set- ting of community practice. 5 A pharmaceutical product can be manufactured with uniform specifications and delivered in a standardized manner. The patient-centered medical home, however, is a multifaceted intervention. It involves changes in the organization, structure, processes, culture, and finan- cial model of a practice. The diverse components include re- defining roles, responsibilities, and tasks for everyone from the receptionists to the physicians; reengineering patient sched- uling templates; performing proactive outreach to high-risk patients; and adopting payment models that blend fee for ser- vice, capitation, and pay for performance. Practice transfor- mation has more in common with continuous quality improve- ment than a rigid clinical trial protocol. There are inevitable compromises between fidelity to the prescribed patient- centered medical home model and adapting the model to the particular circumstances and context of different practices. Things get messy. To evaluate practice interventions, such as the patient- centered medical home, researchers often must capitalize on natural experiments over which they have little control. A con- sequence of evaluating a natural experiment is that studies are frequently underpowered to detect clinically important ef- fects, as was the case in Rhode Island. Quantitative meta- analyses that integrate findings across studies may compen- Related article Patient-Centered Medical Home Invited Commentary jamainternalmedicine.com JAMA Internal Medicine Published online September 9, 2013 E1 Downloaded From: http://archinte.jamanetwork.com/ by a Harvard University User on 09/10/2013
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Great Artificial By Kevin on the research around PCMH a great read for anyone interested in Healthcare transformation.
Transcript of Patient Centered Medical Home (PCMH) is not a pill Kevin Grumbach 2013
Invited Commentary
The Patient-Centered Medical Home Is Not a PillImplications for Evaluating Primary Care ReformsKevin Grumbach, MD
The patient-centered medical home (PCMH) is not a pill. Itwould be much easier to evaluate this primary care reform ifit were.
In this issue of JAMA Internal Medicine, Rosenthal et al1
report their evaluation of the pilot program of a patient-centered medical home model of primary care at 5 practicessupported by a consortium of 3 Rhode Island health insur-ance plans. Findings on patient outcomes were mixed. Dur-
ing the 2-year postinterven-tion period, patients in thepilot practices had 11.6%fewer emergency depart-
ment visits that were potentially avoidable compared withmatched control patients in other practices, with a nonsignifi-cant decrease of 5.2% in total emergency department visits.A similar trend was observed for hospital admissions, with non-significant decreases of 15.1% for potentially avoidable admis-sions and 2.9% for total admissions. No significant differ-ences were found in diabetes care and cancer screening,although colon cancer screening rates increased by a sizablebut not significant 37% during the postintervention period.
Primary care advocates may conclude from this study thata significant reduction in potentially avoidable emergency de-partment visits and strong trends in favorable outcomes foravoidable hospitalizations and colon cancer screening add tothe evidence that supports redesigning primary care. Skep-tics may conclude that the lack of significant differences inquality measures and overall use is evidence of the lack of ef-fectiveness. Thus, it is important to place in context evalua-tions of the patient-centered home model.
If the patient-centered medical home were a pharmaceu-tical product, research to justify Food and Drug Administra-tion approval would need to demonstrate safety and thera-peutic benefit. By this standard, the substantial efficacy of thepatient-centered medical home for colon cancer screening andthe lack of reporting of any patients in the 5 practices who hadbad care experiences would support approving the patient-centered medical home as an efficacious and safe product. Thisconclusion would be bolstered by a recently published sys-tematic review of patient-centered medical home evalua-tions that found “a small positive effect on patient experi-ences and small to moderate positive effects on the deliveryof preventive care services.”2(p175) As is the case for new medi-cations, expectations that health plans pay for practice rede-sign would follow soon after regulatory approval.
No such luck for the patient-centered medical home. It isnot enough for it to be nonharmful and to demonstrate somedegree of efficacy. In many quarters, the patient-centered medi-cal home is judged on whether it is a “home run” for the ills ofthe US health system3—specifically, a 3-run homer achieving
the triple aims of better health, better patient experience, andlower costs. Reducing overall costs is a paramount aim for theCenters for Medicare and Medicare Services and other pay-ers. The ability to generalize payment reform for primary carebeyond the current pilot and demonstration projects largelydepends on the ability of the Centers for Medicare and Medi-care Services to convince the actuaries at the Office of Man-agement and Budget that the reforms cost the federal govern-ment no more—and ideally less—than would otherwise havebeen spent.
Clamor for the reforms that are part of a patient-centeredmedical home reflects the broad recognition that health sys-tems do not function effectively or efficiently without a strongfoundation of primary care and alarm that this foundation iscrumbling in the United States. Revitalizing primary care re-quires an infusion of resources and changes to care delivery.4
Of course, primary care is deprived of resources and under-valued and consumes only approximately 6% of total healthcare spending in the United States. So, it is legitimate to ques-tion the reasonableness of making an investment in the revi-talization and retooling of primary care contingent on promptly“bending the cost curve” for the remaining 94% of health carespending.
Those who evaluate patient-centered medical home in-terventions contend with finding sensible methods for study-ing complex changes in health care delivery in the dynamic set-ting of community practice.5 A pharmaceutical product can bemanufactured with uniform specifications and delivered in astandardized manner. The patient-centered medical home,however, is a multifaceted intervention. It involves changesin the organization, structure, processes, culture, and finan-cial model of a practice. The diverse components include re-defining roles, responsibilities, and tasks for everyone from thereceptionists to the physicians; reengineering patient sched-uling templates; performing proactive outreach to high-riskpatients; and adopting payment models that blend fee for ser-vice, capitation, and pay for performance. Practice transfor-mation has more in common with continuous quality improve-ment than a rigid clinical trial protocol. There are inevitablecompromises between fidelity to the prescribed patient-centered medical home model and adapting the model to theparticular circumstances and context of different practices.Things get messy.
To evaluate practice interventions, such as the patient-centered medical home, researchers often must capitalize onnatural experiments over which they have little control. A con-sequence of evaluating a natural experiment is that studies arefrequently underpowered to detect clinically important ef-fects, as was the case in Rhode Island. Quantitative meta-analyses that integrate findings across studies may compen-
Related article
Patient-Centered Medical Home Invited Commentary
jamainternalmedicine.com JAMA Internal Medicine Published online September 9, 2013 E1
Downloaded From: http://archinte.jamanetwork.com/ by a Harvard University User on 09/10/2013
sate for the limited power of individual studies, butheterogeneity among studies of patient-centered medical homesoften precludes such an approach.2 Moreover, in the study byRosenthal et al, 2 years of follow-up may have been too shortfor full implementation of the intervention and for evaluatingthe intervention’s effects on outcomes. No doubt Rosenthal etal would have preferred to study more than 5 practices and tocontinue the evaluation beyond 2 years of follow-up.
When all the available information is imperfect, organiza-tions must make strategic decisions. Decision makers use a col-lage of scientific evidence, case studies, and their own hunches.For example, the Department of Veterans Affairs (VA) has a re-markable trajectory of quality improvement during the past 20years. A critical ingredient has been the VA’s investment instrengthening primary care and implementing its own patient-centered medical home model known as the Patient AlignedCare Team.6 In 1994, when the directive committing the na-tional VA system to primary care transformation was issued,leaders of the department did not wait before acting for a pooledP< .05 from a meta-analysis of patient-centered medical home
evaluations. The sponsors of the Rhode Island patient-centered medical home initiative likewise seem to consider theexternal evaluation by Rosenthal et al and their own internaltracking data sufficiently compelling to commit to supporting20 additional practices per year for the next several years.7
Research on primary care transformation in the UnitedStates is important, using methods of evaluative and imple-mentation science suitable to the complexity of the topic. Theinformation generated provides critical formative feedback tothose implementing patient-centered medical home modelsand an overall sense of whether the movement to reform pri-mary care is headed in the right direction. Policymakers, how-ever, will do the public a disservice if they wait for incontro-vertible scientific evidence that the patient-centered medicalhome is a magic triple aim pill with a large and immediate fi-nancial return on investment. The patient-centered medicalhome is neither a pill nor a wonder drug. On the basis of theavailable evidence, insurers, the states, and the federal gov-ernment should act to revitalize the indispensable primary carefoundation of our health system.
ARTICLE INFORMATION
Author Affiliation: Center for Excellence in PrimaryCare, Department of Family and CommunityMedicine University of California, San Francisco.
Corresponding Author: Kevin Grumbach, MD,Center for Excellence in Primary Care, Departmentof Family and Community Medicine, University ofCalifornia, San Francisco General Hospital, 1001Potrero Ave, Ward 83, San Francisco, CA 94110([email protected]).
Published Online: September 9, 2013.doi:10.1001/jamainternmed.2013.7652.
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Rosenthal MB, Friedberg MW, Singer SJ, EastmanD, Li Z, Schneider EC. Effect of a multipayerpatient-centered medical home on health care
utilization and quality: the Rhode Island ChronicCare Sustainability Initiative pilot program[published online September 9, 2013]. JAMA InternMed. doi:10.1001/jamainternmed.2013.10063.
2. Jackson GL, Powers BJ, Chatterjee R, et al. Thepatient-centered medical home: a systematicreview. Ann Intern Med. 2013;158(3):169-178.
3. Milstein A, Gilbertson E. American medical homeruns. Health Aff (Millwood). 2009;28(5):1317-1326.
4. Grundy P, Hagan KR, Hansen JC, Grumbach K.The multi-stakeholder movement for primary carerenewal and reform. Health Aff (Millwood).2010;29:791-798.
5. Peikes D, Petersen D, Zutshi A, Meyers D,Genevro J. Expanding the toolbox: methods to
study and refine Patient-Centered Medical Homemodels. PCMH Research Methods Series, AHRQpublication 13-0012-EF, March 2013.http://pcmh.ahrq.gov/ExpandingtheToolkit.Accessed June 26, 2013.
6. Yano EM, Simon BF, Lanto AB, Rubenstein LV.The evolution of changes in primary care deliveryunderlying the Veterans Health Administration’squality transformation. Am J Public Health.2007;97(12):2151-2159.
7. Patient-Centered Medical Home Rhode Island.The Rhode Island Chronic Care SustainabilityInitiative, Fact Sheet v1.0. http://www.pcmhri.org/files/uploads/CSI-RI%20fact%20sheet%201-14-2013%20V1.0.pdf. Accessed June 26, 2013.
Invited Commentary Patient-Centered Medical Home
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