The Patient‐Centered Medical Home and Patient Experience

Objective

To examine the relationship between practices'' reported use of patient-centered medical home (PCMH) processes and patients'' perceptions of their care experience.

Data Source

Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.

Study Design

This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients'' care experience and the use of PCMH processes in the practices where they receive care.

Data Collection

We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.

Principal Findings

We found that practices'' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.

Conclusions

In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.     

Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.     

医疗之家及其对我国卫生管理的借鉴意义

扩大基本卫生服务是改善群体健康、减低医疗花费的重要举措.介绍了美国当前被广泛推崇的—种基本卫生服务理念——医疗之家（patient centered medical home,PCMH）,详细分析了其特点及实施过程,并探讨了PCMH在我国基本卫生管理中的应用前景.     

The Cost of Sustaining a Patient-Centered Medical Home: Experience From 2 States

PURPOSE

As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these “advanced primary care” functions. A key required input is personnel effort. This study’s objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards.

METHODS

We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions.

RESULTS

Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado.

CONCLUSIONS

Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.     

The impact of patient‐centered medical homes on medication adherence?

Accreditation of providers helps resolve the pervasive information asymmetries in health care markets. However, meeting accreditation standards typically involves flexibility in implementation, leading to heterogeneity in performance. For example, the patient‐centered medical home (PCMH) is a leading model for recognizing high‐performing primary care practices. Flexibility in PCMH implementation allows for varying degrees of emphasis on processes designed to enhance medication adherence. To assess the impact of the PCMH on adherence, we combine 6 years of detailed patient claims data with a novel dataset containing detailed practice‐level PCMH attributes. We study the effects of the number and configuration of adherence‐relevant capabilities, using variation in the timing of PCMH adoption to estimate its impact. While PCMH adoption improved overall medication adherence, when combining claims data with the unique recognition data detailing what PCMH capabilities were adopted, we find that these gains are concentrated among patients in practices that adopted more adherence‐relevant capabilities. Despite mixed evidence in the literature concerning costs and utilization, our results indicate that PCMH recognition improves medication adherence.     

Recommendations for a Mixed Methods Approach to Evaluating the Patient-Centered Medical Home

PURPOSE

There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups.

METHODS

To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion.

RESULTS

The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment.

CONCLUSIONS

This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices.     

Care From Family Physicians Reported by Pregnant Women in the United States

PURPOSE

We describe the proportion of family physicians providing care of any sort to pregnant women in the United States from 2000 to 2009.

METHODS

We used a repeat, cross-sectional design with data from the nationally representative Integrated Health Interview Series (2000–2009) for respondents who reported being pregnant at the time of the survey (N = 3,204). Using multivariate logistic regression, we modeled changes over time in pregnant women’s reports of care from family physicians. We used interaction terms to test for regional differences in trends.

RESULTS

Approximately one-third of pregnant women reported having seen or talked to a family physician for medical care during the prior year, a percentage that remained stable for the period of 2000 to 2009 (adjusted odds ratio for annual change = 1.006). Most pregnant women reported care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners, and physician assistants. There were regional differences in trends in family physician care; pregnant women in the North Central United States increasingly reported care from family physicians, whereas women in the South reported a decline (6.7% annual increase vs 4.7% annual decrease, P ≥.001).

CONCLUSIONS

Trends in family medicine care for pregnant women have remained steady for the nation as a whole, but they differ by region of the United States. Most pregnant women reported care from multiple clinicians, highlighting the importance of care coordination for this patient population.     

Patient-centered medical homes in the United States

The concept of a medical home is receiving increased attention as a potential means to improve care and reduce costs. This study describes the characteristics and capabilities of practices that have achieved recognition of National Committee for Quality Assurance as a "patient-centered medical home" (PCMH). Both small and large practices demonstrate capabilities related to the goals of PCMH of accessible, coordinated, and patient-centered care; however, practices affiliated with larger organizations achieve higher levels of PCMH recognition compared with unaffiliated small practices. Efforts to support practices to implement medical home capabilities are needed, particularly in the use of data for population management and patient self-management.     

Journey toward a patient-centered medical home: readiness for change in primary care practices

Context: Information is limited regarding the readiness of primary care practices to make the transformational changes necessary to implement the patient‐centered medical home (PCMH) model. Using comparative, qualitative data, we provide practical guidelines for assessing and increasing readiness for PCMH implementation. Methods: We used a comparative case study design to assess primary care practices’ readiness for PCMH implementation in sixteen practices from twelve different physician organizations in Michigan. Two major components of organizational readiness, motivation and capability, were assessed. We interviewed eight practice teams with higher PCMH scores and eight with lower PCMH scores, along with the leaders of the physician organizations of these practices, yielding sixty‐six semistructured interviews. Findings: The respondents from the higher and lower PCMH scoring practices reported different motivations and capabilities for pursuing PCMH. Their motivations pertained to the perceived value of PCMH, financial incentives, understanding of specific PCMH requirements, and overall commitment to change. Capabilities that were discussed included the time demands of implementation, the difficulty of changing patients’ behavior, and the challenges of adopting health information technology. Enhancing the implementation of PCMH within practices included taking an incremental approach, using data, building a team and defining roles of its members, and meeting regularly to discuss the implementation. The respondents valued external organizational support, regardless of its source. Conclusions: The respondents from the higher and lower PCMH scoring practices commented on similar aspects of readiness—motivation and capability—but offered very different views of them. Our findings suggest the importance of understanding practice perceptions of the motivations for PCMH and the capability to undertake change. While this study identified some initial approaches that physician organizations and practices have used to prepare for practice redesign, we need much more information about their effectiveness.     

The impact of patient‐centered medical home certification on quality of care for patients with diabetes

ObjectiveTo identify the impact of changes surrounding certification as a patient‐centered medical home (PCMH) on outcomes for patients with diabetes.Study SettingMinnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient‐level quality reporting data (2008‐2018) were used to study the impact of transition to a PCMH.Study DesignAchievement of Minnesota''s optimal diabetes care standard—in aggregate and by component—was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient''s primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice‐level random effects captured time‐invariant characteristics of practices and the practices’ average patient.Data CollectionElectronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin.Principal FindingsThe first cohort of practices achieving PCMH certification (July 2010‐June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014‐June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage‐point improvement (P < .001) in the predicted probability of providing optimal diabetes care over the period spanning 3 years before to 3 years after certification.ConclusionsOur results suggest that the initial cohort of certified practices was already performing at a high level before certification, perhaps requiring little change in their operations to achieve PCMH certification. The second cohort, on the other hand, made meaningful, quality‐improving changes in the years surrounding certification. Differences by cohort may partially explain the inconsistent PCMH impacts found in the literature.     

Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes

Objective

To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.

Data Sources

Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.

Study Design

This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.

Data Collection Methods

Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.

Principal Findings

Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.

Conclusions

This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.     

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services.METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling.RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services.CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.     

Progress of Ontario's Family Health Team model: a patient-centered medical home

Ontario's Family Health Team (FHT) model, implemented in 2005, may be North America's largest example of a patient-centered medical home. The model, based on multidisciplinary teams and an innovative incentive-based funding system, has been developed primarily from fee-for-service primary care practices. Nearly 2 million Ontarians are served by 170 FHTs. Preliminary observations suggest high satisfaction among patients, higher income and more gratification for family physicians, and trends for more medical students to select careers in family medicine. Popular demand is resulting in expansion to 200 FHTs. We describe the development, implementation, reimbursement plan, and current status of this multidisciplinary model, relating it to the principles of the patient-centered medical home. We also identify its potential to provide an understanding of many aspects of primary care.     

The Dissenter’s Viewpoint: There Has to Be a Better Way to Measure a Medical Home

The patient-centered medical home (PCMH) is widely touted as the current pathway to high-quality primary care practice. Many payers and institutions are using the formal National Committee for Quality Assurance (NCQA) PCMH tool to evaluate practices. Practices commonly feel pressured financially to achieve NCQA recognition. As 2 small high-functioning innovative primary care practices, we describe the actual process of using this tool and assess its utility using a framework based on patient experience of care, costs, and population health. We both attained certification as Level 3 PCMHs but conclude that NCQA’s tool mismatches form and function, is costly and wasteful, and may succeed more in documentation of policies than in supporting improved outcomes in practices.     

Characteristics of medical practices in three developed managed care markets

OBJECTIVE: To describe physician practices, ranging from solo and two-physician practices to large medical groups, in three geographically diverse parts of the country with strong managed care presences. DATA SOURCES/STUDY DESIGN: Surveys of medical practices in three managed care markets conducted in 2000-2001. STUDY DESIGN: We administered questionnaires to all medical practices affiliated with two large health plans in Boston, MA, and Portland, OR, and to all practices providing primary care for cardiovascular disease patients admitted to five large hospitals in Minneapolis, MN. We offer data on how physician practices are structured under managed care in these geographically diverse regions of the country with a focus on the structural characteristics, financial arrangements, and care management strategies adopted by practices. DATA COLLECTION: A two-staged survey consisting of an initial telephone survey that was undertaken using CATI (computerized assisted telephone interviewing) techniques followed by written modules triggered by specific responses to the telephone survey. PRINCIPAL FINDINGS: We interviewed 468 practices encompassing 668 distinct sites of care (overall response rate 72 percent). Practices had an average of 13.9 member physicians (range: 1-125). Most (80.1 percent) medium- (four to nine physicians) and large-size (10 or more physicians) groups regularly scheduled meetings to discuss resource utilization and referrals. Almost 90 percent of the practices reported that these meetings occurred at least once per month. The predominant method for paying practices was via fee-for-service payments. Most other payments were in the form of capitation. Overall, 75 percent of physician practices compensated physicians based on productivity, but there was substantial variation related to practice size. Nonetheless, of the practices that did not use straight productivity methods (45 percent of medium-sized practices and 54 percent of large practices), most used arrangements consisting of combinations of salary and productivity formulas. CONCLUSIONS: We found diversity in the characteristics and capabilities of medical practices in these three markets with high managed care involvement. Financial practices of most practices are geared towards rewarding productivity, and care management practices and capabilities such as electronic medical records remain underdeveloped.     

Are Primary Care Practices Ready to Become Patient‐Centered Medical Homes?

Purpose: To measure the readiness of rural primary care practices to qualify as patient‐centered medical homes (PCMHs), one step toward participating in changes underway in health care finance and delivery. Methods: We used the 2008 Health Tracking Physician Survey to compare PCMH readiness scores among metropolitan and nonmetropolitan primary care practices. The National Committee on Quality Assurance (NCQA) assessment system served as a framework to assess the PCMH capabilities of primary care practices based on their services, processes, and policies. Findings: We found little difference between urban and rural practices. Approximately 41% of all primary care practices offer minimal or no PCMH services. We also found that large practices score higher on standards primarily related to information technology and care management. Conclusions: Achieving the benefits of the PCMH model in small rural practices may require additional national promotion, technical assistance, and financial incentives.