2021/04/19 by Marisa Elena Domino · 1 citation
Health Professions · Economics, Econometrics and Finance · Business, Management and Accounting · #Primary Care and Health Outcomes #Healthcare Policy and Management #Healthcare Systems and Technology
paper · doi:10.1111/1475-6773.13661
The concept of the Patient-Centered Medical Home (PCMH) as a way to transform primary care is not new, having been introduced in pediatrics in 1967.1 The Agency for Healthcare Research and Quality (AHRQ) identifies the PCMH as primary care practices incorporating five broad principles of care: comprehensive, team-based, coordinated, accessible, and evidence-based.2 This model of care has received considerable attention in the health service literature, with almost 1500 publications as of this writing that use this term in PubMed alone. Yet one of the many lessons in Carlin et al3 is that the PCMH is not a single model of care, but a broad set of definitions that are recognized by a number of organizations, including the National Committee for Quality Assurance, AHRQ, states such as Minnesota and North Carolina, payers, and various provider/practice organizations.4 However, being recognized as a PCMH involves its own process, which can be costly to practices5, 6 without a direct long-term reward. In my own work, I have heard the PCMH characterized as one of the many examples of check-the-box medicine.7 Research findings from the PCMH on a wide variety of outcomes and patient populations have not been universally positive or even strong and are often tepidly described as “mixed.” While often classified as an “alternative payment model”,8 the PCMH by itself is generally associated with relatively weak financial incentives. Some payment systems or demonstration models, such as Minnesota's Health Care Home mechanism or the Center for Medicare and Medicaid Services (CMS)’s Multi-payer advanced primary care practice demonstration,9 pay a fixed PMPM to practices that earn PCMH recognition, regardless of improvements in patient outcomes or decreases in costs. These PMPM payments are often low and require practices to couple together enough PCMH patients to make investing in this transformation worthwhile. PCMH models are seldom directly incentivized to lower costs, but many practices may use the PCMH as a stepping stone to participating in an accountable care organization, where practices can share in savings generated after quality thresholds are met.10 It is therefore no surprise that studies like Carlin et al3 that focused their analysis on the quality of care for patients with diabetes after state legislation created a population-based registry of diabetes care measures or Hinde et al11 that examined spillover effects of a Medicaid PCMH to private payers, have found that early adopters of the PMCH may be considerably different from those that took several years to implement the model. These early practices may have operated as a PCMH prior to official recognition and continue to do so afterward; the PCMH seal of approval may allow them to gain recognition from their health system or others of this status but not otherwise make meaningful changes. What may be more surprising, however, are the many examples where practice transformation to the PCMH resulted in improved health outcomes and even lower costs. Carlin et al3 find significant improvements in diabetes care outcomes concentrated among practices that were not recognized as PCMHs in the first four years of MN’s program, but instead may have needed more time to meet the multidimensional criteria to be recognized as a PCMH through actual practice changes. This type of careful research at the practice level that goes beyond a simple binary measure of PCMH status could catalyze a new generation of PCMH studies that unpack the essential elements of the PCMH that can actually lead to better care and better patient outcomes, while not increasing patient costs. This is not a new idea but has already been achieved through studies that have accessed information on the “secret sauce” that allows practices to achieve recognition.12 David et al, for example, found that practices with meaningful improvements in tools such as decision support and population management, as well as enhanced access to care, are associated with consequential changes affecting utilization and costs. Clearly, the heterogeneity in outcomes and populations observed in the PCMH literature can push the health services research community to undertake a different type of research study that can unpack the elements of the PCMH that may actually lead to practice improvements for certain populations in certain settings. While PCMH is still ultimately a practice, rather than payer, transformation, and thus hard to dole out to select patients within a practice, certain elements may be more influential when targeted toward specific individuals rather than applied indeterminately across populations with a range of conditions and disease severity. Some of the work unpacking the complex PCMH model that needs to take place in the research literature is the explicit recognition that PCMHs do not operate in a simple service and payor environment. The decision to undertake the PCMH recognition process by a state, payer, or national organization is embedded in a multitude of complex and costly practice decisions: whether to participate in an accountable care organization or not, and with which partners and payors, and whether to accept bundled payments for certain conditions. PCMH status is likely highly interdependent with these other decisions, and thus, a granular dismantling study would need to examine whether these elements of the broader practice environment are reinforcing or possibly competing. As acknowledged by many PCMH studies, the decision to transform a primary care practice to meet any model may be endogenous to the quality or cost outcomes under investigation, a sequalae of desire by some practices to stay on top of the quality curve, and thus may pick up more than the moment of documentation itself. Newer alternative payment models of primary care, including CMS’s Primary Care First Model13, 14 intersect PCMH concepts but directly incentivize better health care outcomes and lower costs. Practices participating in this CMS demonstration in the 26 regions take a step away from fee-for-service medicine by accepting a population-based payment, which is risk adjusted by patient severity of illness through a separate forthcoming option for the seriously ill population, and two-sided, asymmetric risk based on reducing costs and improving quality. While the quality measures appear to still lack direct incentives for improving health care equity for marginalized populations, for improving behavioral health care, and may prove more challenging in rural areas, common concerns among other alternative payment models,15-17 the more direct set of incentives from this demonstration could lead to greater movement in improving outcomes and lowering costs. As the front door to the country's health care system, primary care faces a disproportionate set of demands to improve access, equity, and quality. There will likely never be a one-size-fits-all model of primary care, but combing incentives that directly challenge deficits in the primary care system, along with structural transformation through models such as the PCMH, may lead to the greatest success. Finding ways to recognize and reward the practices that have undertaken the hard work to make meaningful change in a way that improves patient outcomes and equity, and even reduce costs for diverse patient populations with enormous variation in health status is a critical challenge. As a research community that recognizes the challenges and promise of primary care, we should seek to better understand the specific components of primary care that allow this transformation to succeed.