The patient-centered medical home (PCMH) model has been shown to deliver better patient care than traditional primary-care practices, but some doctors won’t want to change.
What makes the model so effective? PCMHs promote a team approach; the focus is on coordinating care between a patient and his or her entire healthcare team across hospitals, specialty-care providers, nursing facilities, and other organizations. In addition, PCMHs leverage the power of health-information technology. And according to a new study in the Annals of Internal Medicine, primary-care doctors who used this team-based approach were more likely to give patients recommended preventive screening and appropriate tests, compared with those working in other settings.
“The PCMH model combines EHRs [electronic health records] with organizational changes, including changes in the roles and responsibilities of clinicians and staff. It was the combination of EHRs plus organizational changes that was associated with the greatest quality improvement,” said lead author Dr. Lisa Kern, an associate professor of healthcare policy and research at Weill Cornell Medical College.
The study compared physicians’ quality of care in PCMHs with care from doctors in non-PCMH practices. The researchers found that simply using technology was not enough to provide better care, and that the PCMH model worked better than non-PCMH practices.
Rebecca A. Malouin, Ph.D., director of Michigan State University’s Primary Care Research and Evaluation Program, explained that the current fee-for-service model makes it financially attractive for primary care doctors to see as many patients as possible—these doctors typically earn less than specialists. The PCMH model can enable the practice to see more patients and provide more contact time with patients. It can take a while to become efficient and adapt to the new model—about one to two years, she said.
“Much of the potential savings from the new model comes from reduced emergency-department and in-patient utilization, which are cost savings to the insurance company or employer, but not necessarily to the primary-care practice,” she said.
Because of these costs, she believes that smaller practices are the least likely to use the PCMH model. And older physicians may not want to overhaul their way of doing things, especially if they are close to retirement—to become a PCMH, a practice must undergo a certification process and demonstrate its performance.
The Affordable Care Act (ACA) promotes PCMHs, and Kern said that more than 7,500 practices across the country are certified PCMHs.
“The PCMH is not necessarily an easy intervention to implement,” Kern said. “It is not a minor modification to usual care but rather a transformation in the culture and delivery of primary care.”
The aforementioned study looked at changes in health care between 2008 and 2010 in 13 primary-care practices that leveraged EHRs and became certified as PCMHs during the study. They compared that information with data from 64 practices that used EHRs but were not PCMHs, along with 235 non-PCMH practices that used traditional print record systems to document and store patient data.
The researchers looked at medical claims from more than 140,000 commercially insured patients across 10 measures such as lipid testing, breast and colorectal cancer screenings, and testing for children with sore throats. Over time, the researchers concluded that PCMHs had between 1 and 9 higher percentage points than non-PCMH practices on four of the 10 measures. They said that receiving recommended care in the PCMHs was 6 percent higher than in practices using only EHRs and 7 percent higher than in the group that used paper records.
What makes a PCMH so different? The authors say that the shift in organizational culture plays a role in improving care.
The Michigan Primary Care Transformation (MiPCT), a statewide PCMH initiative, involves 350 primary-care practices, 36 physician organizations, and about one million patients. Amanda First, a project associate with MiPCT, said PCMHs see fewer patients than non-PCMH practices.
“PCMH practices have both higher costs and higher revenue, indicating that more services are being provided per patient,” she said.
PCMHs had higher costs and higher revenue than non-PCMH practices: $245.79 per patient per year, compared with $177.11 per patient per year, respectively. To launch a PCMH, some up-front costs include EHR and fees for maintenance, plus training expenses along with additional staff to supplement practice expertise. Lorenzo Moreno, a senior researcher at Mathematica, said the cost to implement EHR is about $25,000 to $40,000—that doesn’t include costs to become a PCMH.
Deborah Peikes, a senior fellow at the same company, reported that some studies say implementing a PCMH can cost anywhere from $23,000 to $90,000 per physician.
This month’s Health Affairs journal reports a study that found a similar model implemented in the Veterans Health Administration facilities did not reduce care costs.