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More Evidence on the Limits of the PCMH

March 17, 2014
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A recent article in JAMA showed the disappointing results of a 3-year study of over 100 certified patient-centered medical homes in southeast Pennsylvania. Basically, it showed only 1 of 11 quality measures improved and utilization and costs were not reduced.

In one of the most narrow-minded statements by the AAFP ever, its current president stated that the PCMH is alive and well despite one negative study (italics added). The academy’s own study of the PCMH showed almost the exact same results of little improvement on quality, no cost savings, and no improvement in the patient care experience. A meta-analysis of PCMH studies published in the Annals of Internal Medicine in 2013  also found few changes in outcomes, except a small increase in quality measures, slightly fewer ER visits, but no decrease in costs.

To be fair, an organization called the Patient-Centered Primary Care Collaborative (PCPCC) has published more favorable outcomes on PCMH demonstration projects.

Following the Annals article, there was a commentary on the Healthcare Blog that talked about the exaggerations in past claims by the PCMH pushers, particularly those from the PCPCC. There are lots of comments after the original post if you’d like to read more of the debate, which I won’t repeat here. I got in there a couple of times. Suffice it to say that the PCMH is a flawed model that does not understand basic medical economic cost-effective realities (assumes prevention saves money, which readers of American HealthScare know is almost always not true), and it does not understand how family physicians deliver better care at a lower cost.

I’m most afraid that the PCMH movement will once again lead family medicine into a trap. In the 1990s, we let others define us as gatekeepers, a term I didn’t like the first time I heard it. It implied we were keeping people from the best care. Now we’re letting others define us not as family physicians who provide comprehensive care for complex patients, but as PCMHs. I believe there are some positive parts of the PCMH vision, especially the original AAFP/AAP/ACP statement, not the NCQA bloated definition (casual readers: you don’t want to know).

I deliver better care at a lower cost, not because I’m the titular head of a PCMH, but because I am a family physician. I just wish my national professional academy had the spine to shout this reality to the country.

3 Responses to More Evidence on the Limits of the PCMH

  1. R Watkins on March 18, 2014 at 7:03 am

    Thank you for writing about this here and for your comments elsewhere on the web.

    The AAFP made a disastrous, maybe fatal, mistake when they decided to announce to the world that a board-certified family physician is incapable of providing comprehensive medical care. No, they said, only those who have bought an expensive certificate from NCQA (which includes a lot of NPs)and paid for an enormous administrative super-structure can be truly “patient-centered” in the care they provide.

    There were many good things in the original definition of the PCMH: in particular, a relationship with a personal physician and fair pay for work performed. The AHRQ version of the PCMH being pushed by PCPCC and others says nothing about a personal physician, NOTHING about paying physicians for their work. It’s all about cutting costs so more money goes straight to the bottom lines of Aetna, United, Cigna, etc.

    The AAFP seems completely oblivious to how the medical home concept has been perverted and become a tool of the for-profit insurers. The leadership seems absolutely unwilling to listen to their membership. What should we do?

    • Richard Young MD on March 18, 2014 at 9:22 pm

      All I know to tell you is keep complaining. A great place is to email a comment to FutureFM@aafp.org. I listened to the first virtual town hall meeting and there was lots of anger at the direction the leadership has taken us the last 10 years. Let’s hope they don’t screw it up this time. Lots of loud voices from the front lines is the only way I know to get them to listen.

  2. Tracie Updike MD on March 20, 2014 at 9:59 pm

    Thank you again for stating the obvious; it’s all about the money! I am working on my revert for 2018 but I won’t be dining it again.

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