Bobbie LeBlanc,
Quality Forum PCMH Program Manager

As the nation continues its efforts to transition from a volume-based health care system to one based on value, there’s been a growing emphasis on patient-centered care. This emphasis has led to a revived interest in the Patient-Centered Medical Home (PCMH) model, which has, in turn, led to a great deal of confusion among health care providers.

So let’s talk about it...

An Egg-cellent Comparison

Few items have received as much scrutiny as the egg.

In 2010, the USDA released a study proving that eating an egg each day had no real negative impact on cholesterol. Two years later, a group of researchers at Western University in Canada announced that extensive studies had revealed conclusive evidence that eggs increased the cholesterol so greatly that eating them was as bad for you as smoking cigarettes.

Those studies are only two of more than four decades’ worth of research into eggs. Over the course of that 40+ years, we’ve been bombarded with conflicting messages about eggs – eat them, don’t eat them, eat them in moderation, don’t eat the yolk, etc. – and every single one of those messages has a study to support it.

The PCMH model of care is much the same way. One day, you’re overwhelmed with studies that say PCMH has been proven to improve quality and outcomes; the next day, you’re bombarded with studies that tout the failure of PCMH. (Surely you didn’t doubt my ability to find a connection between eggs and PCMH, did you?)

Doing The Head-Scratch

In an environment that’s jam-packed with these contradictory studies, physicians considering adoption of the PCMH model are undoubtedly scratching their heads and wondering which study to believe.

Is it the Patient-Centered Primary Care Collaborative’s study, which says the PCMH model is responsible for demonstrated improvements in cost, utilization, population health, prevention, access to care and patient satisfaction?

Or is it the study that appeared in The Journal of the American Medical Association, which found “limited improvements in quality” and argued that PCMH “was not associated with reductions in utilization of hospital, emergency department or ambulatory care services or total costs over three years”?

No matter which way you want to argue the issue, you’re guaranteed to find a study somewhere to support your argument. Obviously, as a passionate advocate of the PCMH model, if you were arguing your case with me, I’d be likely to point you to the study published in the American Journal of Managed Care, which revealed that advanced PCMH implementation was associated with total cumulative cost savings of 7.1 percent over a four-year period.

And for good measure, I’d probably tell you about the Annals of Internal Medicine’s analysis that compared the quality of care provided by PCMH physicians with the care provided by EHR-enabled, non-PCMH physicians, and found that the PCMH physicians were six percent more likely to achieve overall quality improvement.

But I’d also be quick to tell you that the vast majority of studies that paint a negative picture of PCMH fail to mention one very important factor in their research: how committed the physicians surveyed were to the PCMH transformation process. The fact is, the PCMH model does work, but only if the physician and his staff are committed to making it work.

Hype Or Hope?

Believe me, as one who works with PCMH recognition-seeking providers in practices of varying sizes and specialties across the state, I’ll be the first to admit that it’s not all just hype: the transformation process can be a difficult – and often confusing – one.

No matter which organization from which you choose to seek accreditation, you’ll face a long list of standards and sub-standards that you have to meet. And yes, that list can be quite daunting, especially to a busy physician with limited staff and resources.

And it’s true, too, that there are costs involved in becoming a PCMH. While these costs will vary depending on certain factors such as practice size, existing capabilities and characteristics of your patient population among others, the PCMH transformation does require an investment on your part.

But remember: Sophocles once said, “Success is dependent on effort.” He also said, “There is no success without hardship.” Both of those quotes apply here because if you’re not committed to understanding the required standards, to learning how to apply those standards and to investing in the process, then no, PCMH is probably not going to work for you.

Can You Handle The Truth?

The truth is, the PCMH model is not a magic wand that will instantly yield improved care and lower costs. It takes time and hard work to see the full scope of benefits, and for many providers, it will require a total departure from the way they’ve always done things. As with anything else, you’ll only get out of it what you put into it.

But as the buzz about PCMH grows louder, so have the misconceptions, which add to the confusion. What misconceptions, you say?

No. 1: Show Me The Money…Please!

There’s a theory floating around that there is no financial gain to be had from becoming a PCMH. It’s true that unlike the EHR Incentive Program, which provides financial incentives to eligible providers who adopt and meaningfully use electronic health records, there are no federal financial incentives (at the present time) for PCMH transformation.

However, there are financial benefits for PCMHs. A growing number of health plans are paying more for PCMH services, and PCMH recognition may also improve your practice’s attractiveness to ACOs, resulting in increased revenue. And let’s not forget that because of the PCMH model’s built-in efficiency, you’ll see more patients, which also equates to increased revenue.

No. 2: I Have To Buy What?

And then there’s the idea that PCMH transformation requires investments in expensive health IT infrastructure, like EHR systems. The truth is, you can achieve lower levels of PCMH recognition without things like EHRs. Of course, health IT is certainly an integral part of higher recognition levels, but its use in a PCMH goes well beyond the requirements of Meaningful Use.

Think of it like this: a carpenter can build a house with a hammer and nails, but he could do it faster and better if he had drills, levels and all those other tools, right? Well, health IT is a tool, too, and while a physician can certainly deliver good care to patients without it, just imagine what that physician could do if he had it - and more importantly, knew how to effectively use it.

No. 3: I Ain’t Got Time For That!

Yet another negative argument about PCMH is that the transformation process will slow down your practice’s daily workflow, when in reality, successful PCMH adoption means you’ll see more patients and reduce their wait times.

Granted, there will be some adjustments in the early stages of the process. Compare it to learning to type back in junior high – you started with the hunt-and-peck method, but as you became accustomed to the layout of the keys and the position of your fingers, your speed increased, and voila, you’d mastered a faster, more efficient way of putting your message on paper. The PCMH transformation process is much the same way – you may start slowly as you adjust to new ways of doing things, but once that adjustment is complete, your practice is flowing faster and more efficiently than ever before.

But Houston, We Have Another Problem…

In my experience, the biggest problem when it comes to getting physicians to consider the PCMH model is the question of quality. As a PCMH advocate, I can’t very well walk up to a physician and say, “Don’t you want to improve the quality of the care you’re providing to your patients?”

If I did, that physician would likely reply, “What – are you saying I don’t provide quality care now?”

And I’d be tempted to say, “Sheesh, don’t be so sensitive,” because of course, that’s not what any of us are implying when we talk about PCMH.

Yet it’s no wonder that physicians are a little touchy when it comes to discussions about quality improvement. After all, you’d be hard-pressed to find an article, a study or even a mention of PCMH that doesn’t include a reference to its potential to improve quality, which can certainly make physicians think PCMH proponents are doubting their ability to provide quality care.

But what those references to quality really mean is that PCMH empowers you, as the physician, to take charge of the patient’s care. That’s what PCMH is about: giving you, the physician, the power to direct the “Big Picture.” It’s about giving you the tools and resources necessary to determine whether Patient X is taking his diabetic medication and how that non-compliance is affecting his overall health as well as its impact on his family.

Those references to quality aren’t about physicians not providing quality care – they’re about incorporating new practices, methods and technologies to enhance the scope of that quality care.

When In Rome…

The bottom line is, Rome was not built in a day, as the saying goes, and neither was the PCMH model. Is there room for improvement within the current model? Of course there is – there’s always room for improvement, just like there’s always room for Jello.

Since its birth back in the ‘60s, the PCMH model has been in an almost constant state of evolution – from a focus on pediatrics to its current holistic, team-based and comprehensive approach to personalized health care for the whole family. And much as a vase will take different shapes while on the potter’s wheel, the model will likely continue to evolve (I bet you’ve already heard of the medical neighborhood, haven’t you?) in response to the evolution of the health care system that’s working to implement it.

The thing to remember here is, the success of the PCMH model, is dependent on that inherent desire among physicians to take care of their patients. You didn’t spend all those years in medical school, endure all that training and take the Hippocratic Oath because you had nothing better to do with your time – you did it because you wanted to play an active role in improving people’s health. Becoming a PCMH is just one more way to do that.

And the fact of the matter is, PCMH is on its way to becoming the new norm in health care. Attribute that to whatever you like, but know this: patients want the advantages of PCMH, and the changes in our health system demand them.

The only question is, are you ready to provide them?