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More Disappointing News on the PCMH

September 6, 2017
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First, I recognize that the whole PCMH experiment was not a total failure. There were some successes. The Patient Centered Primary Care Collaborative (PCPCC) puts out an annual review on PCMH demonstration sites that is always positive. On the other hand, the AAFP PCMH National Demonstration Project was mostly a failure.

Two new studies have shed more light on the effectiveness of PCMHs to deliver bottom-line outcomes. First is a study of PCMHs in federally qualified health centers (FQHCs). Both care management fees and technical assistance was provided to 503 FQHCs across the country to help them reach tier 3 NCQA PCMH status from 2011 to 2014. All the other FQHCs served as comparison sites. Demonstration (PCMH) sites had a relative growth in patient visits (83/1000 pts). Only 2 processes improved: annual DM eye exams (1.3% increase) and annual DM nephropathy tests (1.6% increase). No other process measures improved. PCMH sites had a larger increase in ER visits, inpatient admissions, and physician expenditures (Medicare part B) (Yes, you read correctly. PCMH outcomes were worse). Nor did PCMH sites improve in most measures of patients’ experiences.

Another study used the PCPCC annual review from 2012-2013 to complete a secondary review of 59 PCMHs. They categorized PCMHs in one of 4 levels, essentially how PCMH-ee they were, with “integrated” being the most committed. They analyzed 6 outcomes: cost reductions, decreased ER/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction. The Results were reported as visual radar graphs. Suffice it to say that none of the models delivered significant success on more than one outcome. The integrated model did anemically better on all 6 measures. The authors did not report concrete numerical outcomes (change in ER utilization or actual cost reduction, e.g.).

The AAFP went all-in on the PCMH 10 years ago instead of first testing the model. There have been a few small successes, but nothing near what this country needs to reduce the costs of its exorbitantly wasteful healthcare system. The original cheerleaders for the PCMH tend to write reviews supporting PCMH outcomes  (The PCPCC people, e.g.). People less invested tend to write less glowing reviews. It kind of reminds me of the evidence that drug-company paid reviewers are more positive than those that are not industry sponsored.

The PCMH does not work well because it doesn’t recognize that family medicine is a complex adaptive system that can’t be controlled with top-down simplistic marching orders or measures (Sorry, I said I’d move on from our Primary Care QI paper, but I can tell I’ll probably come back to it often). It’s time to put the PCMH model in our rear view mirror and test more innovative approaches to family medicine that recognize its complexity and assess the actual drivers of family medicine quality.

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One Response to More Disappointing News on the PCMH

  1. A Patrick Jonas on September 7, 2017 at 3:06 am

    Great post! Keep up the good work of honestly reflecting on issues in health care. The Payment Centered Medical Home never got the right name. It never was Patient Centered.

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