Millions of Affordable Care Act funding dollars have gone to support Patient Center Medical Home (PCMH) development to create and further develop the PCMH model within health centers. PCMHs were created in efforts to achieve the Triple Aim: a three part goal which focuses on quality of care, overall improvements to health and cost reduction within the primary care space, especially for those with multiple complex health issues. PCMHs try to achieve this aim through a team-based approach and well-managed, integrated care coordination, and they have gained support in this new era of health reform. Let’s take a look at how some of them are doing:
STAND-OUTS: WHO IS MAKING THE PCMH MODEL LOOK EASY?
Kaiser Permanente’s Mid-Atlantic Medical Centers have become PCMH stand outs, as they were recently recognized by the National Committee on Quality Assurance (NCQA) for achieving Level III ratings for all 29 of its medical centers. They scored high marks in terms of access, use of health information technology to promote information sharing, and coordinated care to control costs and limit waste. Insurers are also looking to use the PCMH model to lower costs – CareFirst Blue Cross Blue Shield of Maryland has been able to slow its pace of spending and has avoided millions in unnecessary costs. Since CareFirst’s 2011 launch of the PCMH model, there have been 19% fewer hospital admissions and 20% fewer readmissions. Although more studies are needed, research shows that a variety of key variables lead to successful implementation of PCMHs, such as effective leadership, strong physician support (including adoption of culture change), up-to-date technology (including electronic health records), payment incentives, and clear communication among the medical home team (physician, nurse, social worker, pharmacist, etc.), as well as with participating health plans.
DOES SIZE MATTER?
While some PCMH initiatives are flourishing due to the characteristics noted above, some PCMHs aren’t yet seeing a robust return on their investment. Although firm conclusions can’t be made based on early research, a JAMA study detailed two regional PCMH pilots within the Pennsylvania Chronic Care Initiative (PACCI) and both regions had different results using the same evaluation methods: the southeast region (urban) did not provide notable results, while the northeast region (rural) did.1 Turns out the northeast region PCMHs were just the right size – neither too big or too small. Why would that matter? The study mentions that a very large practice might change too slowly, and a small practice may not have the resources to handle such an organizational shift. Northeast PACCI physicians also seemed to be more engaged and eager for PCMH adoption, while the southeast PACCI physicians have a more socio-disadvantaged population, which could have added to the stress of adopting a new model. In addition to the urban and rural dichotomy between the southeastern and northeast regions, respectively, payment structures differed among the regions: at the time of the study, the northeast region included a shared savings financial incentive, while the southeast region offered no new incentives linked to the quality and costs of care.
THERE’S STILL WORK TO BE DONE!
While the PCMH model clearly has benefits, it’s important to remember that there are still murky areas that need further research and clarification:
- Currently, no uniform measure exists to evaluate medical homes. While NCQA awards PCMHs levels of recognition for adopting the PCMH model (more than 10% of primary care practices are recognized as PCMHs by NCQA), a clear, standard and uniform measure to evaluate medical homes is still needed, which will also provide a better picture as to their overall impact.
- More research is needed to determine critical elements necessary for PCMHs to achieve specific Triple Aim goals.
- A RAND study published via the journal of Implementation Science shows that there is still a need to determine what resources primary care staff actually use (and what resources they need that aren’t currently available) to implement a PCMH.
- A 3-year study showed that financial incentives encourage PCMH adoption – if physicians lower costs through the PCMH model, they are rewarded. Should this concept be more widely adopted?2
Redesigning the primary care space to offer integrated, coordinated care using a team approach to enhance quality of care, improve health and reduce costs is challenging. The PCMH model offers hope: while some adopters of this model aren’t yet finding their groove, we have success stories and evidence of health care savings. It takes years to see big results when doing such a major transformation like this, and to already have examples of success should be a motivating reminder that different models of care delivery can be adopted and can produce better outcomes and savings. Early evidence shows that PCMHs are responsible for decreases in the cost of care and unnecessary use of medical services, improvements in access to care and patient satisfaction.3 As PCMHs grow in popularity, standards of implementation and operation for different sized health care organizations will hopefully be developed – it would be worth the investment.
1. RAND (2015). Nature and Nurture: What’s Behind the Variation in Recent Medical Home Evaluations?
2. RAND and JAMA Internal Med (2015). Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care.
3. Patient-Centered Primary Care Collaborative (2014). The Patient-Centered Medical Home’s Impact on Cost and Quality: An Annual Update of The Evidence, 2012-2013.