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Assessments Of Community Health Centers As Medical Homes May Be Flawed

February 16th, 2012

One of the initiatives in the Affordable Care Act of 2010 is the expansion of community health centers to provide primary care to millions of newly insured, low-income Americans. The same law promotes the patient-centered medical home model. A community center’s qualifications to be classified as a patient-centered medical home are evaluated through an assessment tool developed by the National Committee for Quality Assurance (NCQA) and endorsed by the federal government.

How well does this tool measure performance on a range of services? A new study, released yesterday as a Web First by Health Affairs, explores that relationship, sampling a group of community health centers in Los Angeles and focusing on diabetes care. It finds no significant relationship between how well these centers performed on the assessment and whether they achieved a range of process or outcome measures for diabetes care.

Robin Clarke and her coauthors at UCLA’s David Geffen School of Medicine collected data at thirty community health centers in Los Angeles County, studying a total of 1,455 diabetic patients. All of the community health centers studied would have qualified as NCQA patient-centered medical homes. The authors observed substantive differences in the quality of diabetes care across the community health centers when checking whether patients had received standard diabetes care evaluations such as blood pressure, HbA1c, or LDL-c testing; kidney disease screening; or eye examinations. However, the presence of more NCQA patient-centered medical home components was not associated with better delivery of diabetes care measures.

“One explanation is that the NCQA tool does not measure the processes that determine the quality of diabetes care with enough sensitivity for a community health center,” conclude the authors. They suggest that future demonstration projects “evaluate how effective enabling services are at overcoming barriers to care and improving chronic disease outcomes.”

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2 Responses to “Assessments Of Community Health Centers As Medical Homes May Be Flawed”

  1. Jeff Goldsmith Says:

    Robert Brook and his colleagues have done the field yet another favor with this paper. The paper stated that most of the clinics he evaluated were not, in fact, certified by NCQA, and if they were, their evaluation scores would have been proprietary and not available to evaluate. And of course, the certification is voluntary, not a requirement to be paid by Medicare or anyone else. Let the buyer beware.

    Read the newer 2011 Standards and Guidelines yourself (Standards and you will understand why the primary care physician “street” refers to the PCMH as the “process centered medical home”. These are well meaning guidelines put together by thoughtful people, but whether there is any empirical link between meeting all these process requirements and actual improvements in patient health is a valid and important question. Brook’s research suggests that the answer is probably “no”.

    While we might want to take another three years and conduct a truly rigorous double blind trial using actual certification scores, etc., we might also want to ask whether there is any cost/benefit relationship between the costs to the medical home provider of maintaining and documenting all these standards (6 standards, 28 elements, 152 factors) and measurable societal benefits in improved health.

    As Bob Berenson suggested in Health Affairs a couple of years ago, the obsession with process, and the heavy emphasis on electronic documentation of core measures stands an excellent chance of killing off this promising idea:

    There’s a pattern here, and you can see the same process (and bureaucracy) intensive approach with meaningful use, PQRI and value based purchasing, the Shared Savings Program. The effect of all these programs is to subtract precious care giver time from actual patient contact and plant them in front of their computers checking boxes. The relationship between cost and benefit has been irretrievably lost. Secretary Sebelius’ merciful suspension of the ICD-10 implementation tells us that someone finally gets it: our front line caregivers are drowning in well meaning but poorly conceived documentation demands. What we really need is a Results Oriented Medical Home.

    Enough is enough.

  2. mOkane Says:

    NCQA is proud of the PCMH program and has been pleased to see it being implemented in many community health centers. Many studies (including ones published in Health Affairs) have shown success in improving access, reducing emergency room use and admissions. We want to note that this particular pilot did not include having NCQA evaluate the practices directly (the usual approach) but rather used the NCQA tool for self assessment. The self-assessment that these centers reported is intended to show where improvement is needed. We have found that documentation of use of the guidelines combined with objective evaluation of that documentation is critical to a accurate conclusion of a clinic’s qualification as a Recognized PCMH by NCQA. Indeed, the language we have in the Survey Tool states that organizations cannot make any representation about their Recognition, or even readiness for Recognition, based solely on self-assessment, because that objective review is so important.

    Margaret O’Kane

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