Today – February 26, 2014 – the Journal of the American Medical Association (JAMA) published the results of a pilot study (note: click the link, and then click the JAMA Reader link button on the right side of the page for the full text) of a volunteer group of Pennsylvania primary care practices. The pilot was designed by a coalition of payers, clinicians, and healthcare delivery systems in the southeastern region of Pennsylvania, and its purpose was to measure the impact, if any, of the patient centered medical home (PCMH) model on outcome/quality improvement and cost containment.
I’ll cut to the chase: the first paragraph of the conclusion states
A multi-payer medical home pilot […] was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over three years. These findings suggest that medical home interventions may need further refinement.
Further along in the conclusion section, the article refers to the patient-centered medical home as “professional associations, payers, policy makers, and other stakeholders, [in a] a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care.” The only trouble with this definition of PCMH is that the patient is not really a part of the team – patients are once again assigned acted-upon rather than actor-in status in the healthcare transaction.
In a highly-readable post on his blog, Dr. John Mandrola boils his observation of the JAMA report down to “health cometh not from healthcare.”
Until the leaders in clinical practice – JAMA and all others in the position to ignite and guide the conversation about medical care, its purpose, and its future – fully recognize the need for a participatory model that starts and ends with the patient, we’ll be reading study reports like the one in today’s JAMA.
Thanks for posting this and including your thoughts. It is discouraging after all this time and all of the hype about Meaningful Use Stage 2 that mandates including the patient, that JAMA could come up with this list of stakeholders and leave out the patient. Little things are happing but way too slowly. For example did you know that CMS has mandated that every ACO organization must include a patient representative with a vote on its board. The patient impact is taking way too long. Let’s hope it is just too little and not too late.
If providers (clinicians and institutions) and payors build PCMHs they will inevitably be tools that function to meet provider and payor goals. If they are to improve health care, they must be built with patients as the core members of the team. Only after patients are in a position to define what they want out of the system, get the data and do the studies to identify the barriers to getting what they want, and then designing systems to overcome the barriers, will the systems serve patients. Seems pretty basic to me.
What Peter said. ‘Cause he said it perfectly.
So, how does one light a fire under the JAMA’s and others, to change their practice, or change their perception of what practice should be?
The ones with the matches to start a fire are us, if we can just get enough kindling gathered up. That involves getting some big system players – payers, particularly – to recognize that until PATIENTS are driving policy and care system design, we’ll be stuck on “stupid.”
There has been a PCMH-like model available for frail older people for many years. It’s called PACE (Program of All-Inclusive Care for the Elderly) and it has improved outcomes. The care is delivered by a team, there is a lot of support for families and caregivers, and generally people seem to like it.
The hitch: PACE programs are usually for people who are nursing home eligible, and they mainly serve people who are dual-eligible (Medicaid & Medicare). In other words, it’s for frail elderly people who are about to cost the state nursing home expenses, so states have an incentive to cover PACE if a program is available.
I wish comprehensive programs like this were available to people earlier on, but in the short-term they are expensive compared to primary care as usual.
The JAMA editorial points out that PCMH might be best for certain high-needs groups. Whether health cometh from healthcare depends in part on what kinds of health problems one is having, and one’s overall level of medical complexity.
Of course, I agree w Peter & Casey that any new models should be developed in partnership with patients and families. On Lok in San Francisco was the original PACE site and began as a community-led effort in the 1970s.