Viewpoint

The Patient-Centered Medical Home: Expensive and in Need of Repair


Peter Boland

The health care industry has a tendency to adopt whatever is new—the shiny thing that seems to address the intractable challenge of providing better care at a lower cost.

At the same time, the industry is reluctant to question whether the proposed new service meets the needs of consumers—with consumers defined as patients, not the providers who take care of them.

If patients are identified as the consumers, as they should be, that leads to a matryoshka nesting doll set of questions. Do clinicians have insight and understanding into what is most important to patients? How do we know what matters most to patients? And can we really trust and support what patients say they value most? What if patients, physicians, hospitals, and insurers are miles apart in what they think is most important? What then?

How these questions are asked and answered can sculpt the contours of health care delivery and design. They are also the stuff out of which performance measures are made and rewards for meeting or exceeding them determined.

Homes, not so sweet

Let’s consider the patient-centered medical home, that model on which so many high hopes have been pinned.

On the one hand, the PCMH is an admirable effort to gather in one place all the disparate and disorganized clinical and social supports the patient needs. Care coordination and caregiver continuity—the PCMH is supposed to take those clunky abstractions and make them a reality.

At the same time, though, medical homes employ provider-defined business models and conventional performance measures, belying the patient-centered in the name. Researchers have found that what patients want is not a major priority of most PCMHs (Wasson 2017, Fiscella 2017).

PCMHs may also be at cross purposes with the odd-couple pairing of better care at a lower cost. They surround patients with a battery of resources that may or may not be needed for a particular case. Having those services ready and available adds expense when the plain fact is that the majority of illnesses are short-term acute conditions that do not require comprehensive case management and costly team-based care. While these services have curb appeal, PCMHs bring together more services and personnel than most patients need, even primary care patients.

Inherent to the PCMH design is extensive monitoring with performance measures that are used to condition payment. However well-intentioned performance measures might be, they add significant operational cost and complexity to any practice model or an episode of care (Williams 2012, Zutshi 2013). A swarm of process and recordkeeping engulfs the actual delivery of care, and care is improved indirectly, if at all.

The elaborate certification process for PCMHs only makes things worse. It overwhelms the capacity of medical homes to deliver cost-effective care (Fineberg 2014). National Committee for Quality Assurance PCMH certification erodes efficiency (Ho 2015). Complexity is often the enemy of efficiency, and efficiency is a prerequisite for sustainability for all health care organizations.

Adding cost causes harm

Another problem is that the NCQA criteria do not take into account very much, if anything, that concerns patients. Patient-reported data and outcomes are more useful for assessing clinical activity in relationship to patient values than the costly documentation process of NCQA certification (Nelson 2015).

This begs the questions of which measures are most important and what do patients need in terms of clinical and social support at any given moment? Both queries raise two defining issues that the health care industry is reluctant to face: What is worth paying for? And what is not worth paying for? A related issue points to a fundamental question of ideology that determines how capital is allocated and according to what criteria. Who determines what is worth paying for today?

The answer is that patients are now in the driver’s seat, like customers in every other industry, and their preferences and values are paramount.

One thing to keep in mind is that over­regulation and overmeasurement do not affect only harried providers. By undermining affordability, it also violates primum non nocere—the guiding principle of “first, do no harm” to patients whatever the intervention or procedure. Most patients and working families can no longer afford insurance premiums and out-of-pocket expenses (Boland 2014). The average deductible for a commercial health plan is now $5,000. Issues like access to care and quality pale in importance when services are priced beyond the reach of most patients.

Many aspects of managed care business models have transferred a disproportionate amount of financial risk from insurers and employers onto the backs of patients. As a result, many patients now forgo care because they cannot afford to pay health plan deductibles at the time of service—in essence, shutting off access.

The PCMH model largely reinforces the traditional business model of managed care but with some added enhancements. In many cases, PCMHs have improved geographic access, provider continuity, and increased patient satisfaction—that is all to the good. But they have failed to reduce costs in a substantial way. And if patients cannot afford to pay for services the way providers currently price them, then PCMHs are not a sustainable business model. Medical housing, like the real estate version, has to be priced so it is within reach. It is as if we are busy building mansions when what most people need—and, indeed, want—is just a decent place to live.

For the PCMH model to survive, its designers (which include payers) will need to strip away needless complexity. Its performance and data experts will need to home in on what patients want and need and avoid tallying metrics that measure what is most convenient to measure rather than what is most important to patients (customers).

What constitutes value to the provider is important, yes. But it should be a distant second to what matters most for patients, which is best reflected in the What Matters Index (Wasson 2018). The What Matters Index points toward what matters with patients rather than the usual approach of what matters to patients. This perspective is an important distinction that reflects a major difference in ideology and medical practice.

Here are three examples of how a patient-centered index can serve as a guide to revamping PCMHs. First, patients, like all other customers, want convenient and efficient service (reducing opportunity costs) and this requires a new emphasis on not only patient engagement but also virtual patient engagement as a cornerstone of patient centeredness. Telephone house calls that precede face-to-face office visits make appointments more focused and facilitate more meaningful communication. Second, health confidence measures go to the heart of how well patients can manage their conditions themselves, including persistent pain and emotional problems. These indications have a significant impact on health and well-being and can be addressed through behavioral interventions. Third, it is essential that patients get exactly the kind of care they want and need. That includes the when, the how, and the where (Wasson 2017).

In short, caregivers, delivery systems, and regulators must wean themselves from the hyper-measurement paradigm that was designed by—and for—providers and insurers. They need to move toward adopting measures that have more meaning to patients and that reduce administrative complexity. Authentic patient centeredness demands no less. Without this fundamental reorientation, the PCMH model is not sustainable.

Peter Boland is a member of the Managed Care editorial advisory board.

References

Boland P, Gibson D. Patient liquidity at time of service: big problem for providers, insurers. Manag Care. 2014;23:39–42.

Fineberg M, Schneider E, Rosenthal M, et al. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311:815–825.

Fiscella K. Commentary on ‘rebuild the patient-centered medical home on a foundation of human needs.’ J Ambul Care Manag. 2017;40:101–106.

Ho L, Antonucci J. The dissenter’s viewpoint: there has to be a better way to measure a medical home. Ann Fam Med. 2015;13:269–272.

Nelson E, Eftimovska E, Lind C, et al. Patient-reported outcome measures in practice. BMJ. 2015;350:g7818.

Wasson J. A troubled asset relief program for the patient-­centered medical home. J Ambul Care Manag. 2017;40:89–100.

Wasson JH, Ho L, Soloway L, Moore LG. Validation of the What Matters Index: a brief, patient-reported index that guides care for chronic conditions and can substitute for computer-­generated risk models. PLoS One. 2018;13:e0192475.

Williams JW, Jackson GJ, Powers BJ, et al. The patient-centered Medical home: closing the quality gap: revisiting the state of the science. AHRQ Publication No. 12-E008-EF. 2012.

Zutshi A, Piekes D, Smith K, et al. The medical home: what do we know, what do we need to know? Mathematica Policy Research and AHRQ. 2013.