Won’t you be my (medical) neighbor?

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Over the past year, the findings of three large demonstrations of the Patient-Centered Medical Home (PCMH) model have been published. It is fair to state that the studies report conflicting results. Kip Sullivan, a Minnesota-based health policy expert brought this topic to the forefront in his blog post on June 7 of this year entitled “The verdict is in. All three of CMS’ medical home demonstrations have failed.”  But, a recent Health Affairs blog post by Paul Cotton entitled “Patient-centered medical home evidence increases with time” begins with one of Mark Twain’s most famous quotes: “The reports of my death are greatly exaggerated”.

So where does the truth lie? I hope to help shine some light on these findings in this post by presenting results of important demonstration projects and offering suggestions for next steps.
The Federally Qualified Health Center - Advanced Primary Care Project Demonstration was hampered by lack of a multi-payer design, limited financial assistance and short duration. In addition, strengthening primary care for vulnerable and underserved patients is likely to be more challenging than in other settings. Also, the endpoint of this demonstration was achievement of Level 3 NCQA recognition as a medical home. This is but one milestone on the journey to true “medical homeness” and is by no means a stopping point.
The Multipayer Advanced Primary Care Demonstration spanned 8 states and enrolled 800 practices. The quality data was inconsistent but overall the demonstration was budget neutral. Participating practices reported ongoing challenges with health information technology and data sharing as well as lack of alignment across payers. Positive findings included effective leadership, high levels of staff support, and cohesive change teams correlated with better outcomes.
The Comprehensive Primary Care (CPC) Initiative did show that quality was slightly improved, patient satisfaction was stable and provider satisfaction was improved while transitioning from fee for service to a value based payment model. CPC did not require external vetting of practices but relied on their attestation that they were fulfilling the requirements of the project. CPC+ will build on this model and recognize that all practices enter the transformation process from different points along a continuum.

Moreover, a September 10th blog post by Paul Cotton in Health Affairs makes a compelling case for why patient-centered medical homes work. https://bit.ly/2NEDP3j Citing multiple journal articles and published evaluations, Cotton concludes that PCMH recognition by NCQA is associated with better clinical and cost performance. As an example, Cotton cites recently published findings in the American Journal of Managed Care that NCQA PCMHs saved Medicaid $214.10 per month for HIV patients with diabetes, chronic lung disease, asthma, congestive heart failure or behavioral disorders. The savings came from inpatient care and outpatient substance use treatment reductions.

Additionally, a recent report by the Patient-Centered Primary Care Collaborative on the relationship between accountable care organizations (ACOs) and medical homes showed that ACOs with more NCQA PCMHs had greater average savings than those with fewer or zero PCMHs. https://bit.ly/1K2Gw8d

For the sake of completeness, there are several other recognition programs including those offered by the Joint Commission and URAC. I look forward to seeing their data about the impact of their programs.

What elements are necessary for success in a medical home?
This is not an all-inclusive list but captures some of the most important factors:

  • Strong leadership– administrative and clinical
  • Widespread buy-in at all levels of a practice
  • TIME!!! (3-5 years is a realistic timeline to see positive results)
  • Willingness to embrace quality improvement principles and practices
  • Adequate financial incentives (both for practice transformation and ongoing care of patients)
  • Multi-payer involvement
  • Ability to generate and act on data from electronic health records
  • Focus on high-risk, high-need patients
  • Effective and efficient health care teams

I have spoken with several thought leaders in the primary care and medical home fields in the last few months about these results and their significance for the future.
A common response was that primary care – no matter how well organized and run it is – can only indirectly affect the cost of care, utilization and outcomes.  Once a patient leaves the primary care office, our ability to influence what happens next is limited. In other words, the patient-centered medical home primary care model is necessary but not sufficient. What is sorely needed is system transformation starting with the primary care and extending throughout and beyond the complex health care system.
In 2010, the American College of Physicians published a position paper called “The PCMH Neighbor: The Interface of the PCMH with Specialty and Subspecialty Practices”.
https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/pcmh_neighbors.pdf.It offered a framework to categorize interactions between practices and put forth a set of principles for care coordination and addressed the importance of incentives for specialty practices. The paper offers standardized referral forms for improved bidirectional communication between primary care and specialist practices including the reason for referral (clinical question), social/medical history, medications, what testing has already been done and what is being asked of the specialist – a procedure; a consultation or co-management of the patient as examples.  
The NCQA has a recognition program called the Patient Centered Specialty Practice which recognizes specialty practices that help coordinate and deliver high quality patient-centered care. This program is designed to complement the PCMH program and to expand its reach. The goal is to encourage excellent care coordination by specialty practices leading to less duplication of procedures and fewer hospitalizations. Participating practices include cardiology, dermatology, obstetrics and gynecology, neurology, urology, orthopedics and oncology among others. Although the PCSP program was created in 2013, uptake by payers has been somewhat slow, not dissimilar to uptake of the PCMH in its early days. The PCSP program has great potential to further strengthen the medical neighborhood.
It is clear that the still-prevalent fee for service payment model does not lend itself to widespread acceptance of the medical neighbor model as envisioned by the ACP. But since 2010, there has been proliferation of telemedicine and virtual visits with specialists including e-consults. One of the pioneers of e-consults is the University of California at San Francisco. These consults provide guidance to primary care physicians across the spectrum of patient care. UCSF reports that PCPs implement specialists’ recommendations in the large majority of cases and few patients subsequently require in-person specialty care related to the reason for the e-consult.
We are already planning the 7th statewide summit on primary care and the health home. The Summit will have a new name: Advancing High Performing Primary Care. And the collaboration between the Texas Health Institute and Texas Medical Home Initiative has a new name as well: The Texas Primary Care Consortium. The 2019 Summit (date and place TBD but likely in June) will focus on system level change, the use of technology in primary care and many other timely topics. Be on the lookout for a save the date email soon.
In closing, let’s celebrate the successes of the patient-centered medical home model of care. Going forward, we need to think big and engage the other members of the complex healthcare universe in which we live and work. The move to value based payment will likely help accelerate this movement by aligning incentives more than ever before. In the meantime, won’t you be my (medical) neighbor?