The Patient-centered Medical Home Movement — Promise and Peril for Family Medicine

John C. Rogers, MD, MPH, MEd

Disclosures

J Am Board Fam Med. 2008;21(5):370-374. 

In This Article

Threats

The opportunity for enhanced reimbursement will probably depend on the principle that practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.[1]

The National Committee for Quality Assurance's (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) Recognition Program[14] will be prominent. The TransforMED Medical Home IQ[10] instrument shows practices how they would score on the NCQA PPC-PCMH Recognition Program standards and identifies explicit changes necessary to achieve that recognition. The threat is that the recognition criteria emphasize infrastructure principles and provide little, if any weight, to care principles. This may distort what is perceived as important in the PCMH movement. Focusing mostly on implementing the infrastructure principles is a risk:

"Early analysis from the NDP [National Demonstration Project] (using both qualitative data and the quantitative scores from 2 waves of patient outcome surveys) does suggest that implementing components of the original TransforMED model does not automatically lead to a patient-centered medical home. A primary focus of the NDP has been implementation of the TransforMED model components and to a certain extent, this focus on technical innovations has competed with efforts to address relationship-centered patient care within the practice."

"Successful implementation of new model components does not automatically lead to the relationship-centered organization, necessary for sustained change and learning. This is understandable, as the hard work of implementing technology and revamping workflow means the difficult task of building practice relationships retreat to the backburner. For the most part, the practices that are relationship-centered were so in the beginning." [12]

 

The threat to family medicine is that a recognition program will emphasize infrastructure and forget that relationship-centered care is the core of the PCMH and that the purpose of infrastructure is to support patient-centered care, not divert from it.

The Patient-Centered Primary Care Collaborative[8] has approximately 150 members representing every major stakeholder group in medical care, including physician associations, health systems, patient organizations, insurance companies, and business groups. A prominent motivation for many of these groups advocating for the PCMH is the payment principle: "Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home."[1] For patient organizations, "added value" seems to mean improved quality of care, for insurance companies it seems to mean cost savings, and for businesses it seems to mean more care for less money. This "value" emphasis holds several threats for us, as raised by Fink in this issue of the Journal.[15] One threat to family medicine is how quality of care is measured. Any family medicine faculty member who has participated in quality improvement efforts knows all too well that the indicators of quality and the data systems for collecting these data can be flawed. Further, individual practices could be penalized if the principle about payment ("It should recognize case mix differences in the patient population being treated within the practice."[1]) is ignored and "cherry-picking" of patients is allowed. A threat, and inequity, is if the insurance companies ignore a powerful principle—"It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting."[1]—and pocket rather than share the savings that family physicians create for them. Another threat is if these stakeholders fail to realize that the PCMH is not a panacea for the rising costs of health care and abandon the PCMH concept when health care costs continue to rise and lead to continuing increases in insurance premiums for businesses.

I may be cynical, but I know that one threat to family medicine will be the PCMH bandwagon where wannabes, lookalikes, and opportunists put out "PCMH" shingles claiming they are a "medical home" and deserve the financial rewards intended for the thousands of family physicians throughout this country who have been unsung real medical homes for decades. The core principles of the PCMH must be upheld to prevent it from becoming just another modification of disease management or carve-out programs.

A most dangerous threat to family medicine will be those who co-op the vision of the PCMH and distort the real meaning of what constitutes a medical home. Our vision, and the vision our leaders have been articulating for just shy of 40 years, is still in many ways a counter-culture vision of relationship-centered, patient-centered, family-centered care that integrates behavioral science into the fabric of our continuing, comprehensive care of patients and families. This is the vision that will realize the promise that the PCMH holds for the health and well-being of our patients and communities.

The PCMH movement may threaten family medicine by the emphasis of the recognition programs on infrastructure, the value orientation focus on cost savings, PCMH imposters, and the possibility of a stolen vision. These threats must not be minimized or ignored. Our general tendency in family medicine is to be modest and to assume benign intent on the part of others. This is fundamental to the power of our patient-centered, family-centered, relationship-centered care. But to counter the real threats to the PCMH and our field, we must be alert, diligent, and skeptical. Our advocacy is not self-centered but for the benefit of our patients and communities whose health and well-being is enhanced by our existence.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....