The patient-centered medical home (PCMH) has received attention as an improved care delivery model for primary care physicians — and possibly also for specialists who serve as principle physicians for patients with particular chronic conditions. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) identified the PCMH model as a presumptively qualifying Alternative Payment Model (APM) that would give physicians higher payments. And a recent summary of the latest evidence found reason for optimism about the potential impact of the PCMH model, not only on quality but also physician morale — raising the hope that the proliferation of the PCMH model might attract more physicians to careers in primary care.
At the same time, more robust studies that have used difference-in-differences analyses—controlling for the likelihood that practices that become PCMHs might be higher performers to start with—had less impressive results, especially regarding health care spending. The evidence summary emphasizes that PCMHs differ in their implementation and performance, and calls for more research to identify which components of the PCMH have the greatest impact.
But there’s a more fundamental issue to consider regarding which aspects of primary care practice make the difference in performance. Many of the versions of the PCMH—and the accompanying recognition instruments that assess practice adoption of the PCMH model—do not assure that the well-established four “pillars” of primary care are robustly adopted by PCMH practices. Rather, it’s simply assumed, despite growing evidence to the contrary, that practices are meeting the “four C’s,” as described by the late Barbara Starfield — providing first contact, continuity, comprehensiveness, and coordination.
We would suggest the current emphasis of PCMH demonstrations and models on the fourth C, care coordination, is partly a reaction to decline in primary care commitments to the three other C’s, contact, continuity, and comprehensiveness — decline that seems to have been simply accepted as facts of life by most PCMH architects. It’s no wonder the PCMH emphasizes care coordination — much of the care received by primary care clinicians’ patients is now being performed by others, without their involvement.
With funding from the Commonwealth Fund, we recently completed a study examining the interaction of advanced primary care practices and accountable care organizations (ACOs). Our approach involved 32 interviews with individuals in primary care practices or leadership roles in ACOs and insurance companies. Here we present information that was not a formal part of the study that will be published.
We asked physicians about the extent to which PCMHs and/or ACOs recognize the importance of the four C’s, and for examples of practical approaches for assuring the presence of these elements of primary care practice as PCMH transformation proceeds. This blog derives from our review of the literature on PCMHs, buttressed by respondents’ comments.
Evidence Of Worsening Primary Care Performance On Three Of The Four C’s
Two Commonwealth Fund international surveys found the U.S. at the bottom on “after-hours” care. Only 29 percent of U.S. physicians said their practice had arrangements to ensure after-hours contact or care for patients other than automated phone referral to emergency rooms. And only 30 percent of patients said it was very or somewhat easy to get care on nights or weekends. This sorry performance exists despite evidence that ready access to one’s primary care physician after business hours is associated with improved patient outcomes and lower emergency room (ER) use.
PCMH expectations typically do include after-hours phone availability and a system for seeing urgent patients during office hours, but not much more. In particular, there is no expectation that PCMH clinicians will actively engage with ER physicians in clinical decision making and the patient’s “disposition” (an unfortunate term used to describe whether a patient will be admitted as an inpatient, observed for a while, or referred back to their community physician for needed follow up).
In our interviews with primary care and ACO physicians, we heard that the traditional conversations between the responsible ER physician and the patient’s regular or covering clinician to discuss disposition rarely take place any more, often resulting in avoidable admissions.
A central expectation associated with continuity is that the primary care physician (and the extended care team) would be a major source of support for patients experiencing health crises and would be an important contributor to decision making for patients because of their familiarity with their patients’ values and preferences. That expectation does not require that physicians be the attending physician of record during a hospital stay, but rather that they participate as needed as a member of the virtual inpatient team — sometimes serving as the patient’s advocate in the growing bureaucratic environment of hospital care today.
Yet, for various reasons, hospitalists and specialists have supplanted the primary care physician — many of whom no longer have anything to do with their hospitalized patients. This, despite evidence that greater continuity—in, during, and out of the hospital—leads to improved patient outcomes. Further, it seems that care provided by hospitalists without active participation by the patient’s regular physician does not improve long-term costs and outcomes. Yet, PCMH assessments generally place no expectations on the primary care physician to participate in hospital care.
A recent review of the literature on comprehensiveness finds a dramatic decline in the extent to which primary care clinicians recognize and meet the majority of their patients’ physical and mental health care needs. This includes prevention and wellness, care for acute and chronic conditions, and comorbid condition management. Yet, we know comprehensiveness is linked to lower health care spending. The deterioration in this aspect of primary care is demonstrated by the fact that between 1999 and 2009, physician referrals (not just from primary care) increased from 41 million to 105 million per year, a 159 percent increase in only a decade.
While many PCMH advocates reasonably emphasize the benefits of a multi-disciplinary care team that advances comprehensiveness (e.g., through care coordinators, health educators, nutritionists, part-time pharmacists), most PCMH assessment tools completely ignore the role of the physicians themselves in providing comprehensive care. Again, there seems to be an implicit assumption that the medical home needs to emphasize coordination in order to make up for the reality that patients inevitably will be getting a lot of their care all over town. The decline in primary care comprehensiveness is simply accepted.
It should be acknowledged that some longtime PCMH proponents place strong reliance on the traditional Starfield pillars of primary care. For example, Bodenheimer and colleagues’ 10 building blocks of high-performing primary care include the four C’s. Stange and co-authors assume that a true PCMH places the enhanced PCMH components in practices that follow the “fundamental tenets of primary care” — that is, the four C’s.
Despite this expert advice, PCMH recognition standards include few expectations that practices in fact adhere to the fundamental tenets of primary care. We suggest that may be why PCMH initiatives typically struggle to generate savings, despite well-intentioned efforts.
We acknowledge that the decline in attention to contact, continuity, and comprehensiveness likely reflects the reality of the “hamster on a treadmill” state of primary care. Asking physicians to take patient or ER calls at 2:00 AM, to interrupt a packed office schedule to make rounds on an inpatient, or to avoid referring when that seems the easiest course to take on a busy day may seem overly ambitious, especially as long as fee-for-service remains the predominant payment approach. Understandably, physicians increasingly value their lifestyle and seek more predictable work hours, so night-call and inconvenient visits to hospitals and nursing homes are not high on their list of things to do — even though that is where their value might best be advanced.
Addressing First Contact Care
In our interviews, we explored the importance of assured, after-hours access to a patient’s practice and continuity into and out of inpatient hospitalization, exploring the extent to which PCMH and ACO priorities address these core elements of traditional, high-quality primary care.
There was general agreement that an ACO was in a position to use its clout to improve often non-collaborative hospital-ambulatory practice communication. At the same time, the interviewees often thought it a primary care physician’s obligation to provide after-hours service, whether or not they were part of an ACO.
Although some PCMH initiatives encourage their practices to offer after-hours availability, such as staying open a few weeknights and perhaps Saturday morning, some respondents emphasized the crucial role of phone contact with patients at all hours. This involves not only direct contact with patients but also with ER staff as part of their evaluation of the patient and, when important, to participate in decision making regarding disposition.
Respondents emphasized that patients often are admitted when the ER doctor has not heard from the patient’s primary care physician and has no assurance that the practice will assume responsibility for the patient’s well-being. One respondent noted that communication between ER physicians and community physicians has deteriorated in recent years, and that the ER often no longer is interested in avoiding an unnecessary hospitalization.
Physicians noted various practical strategies to assure first contact care after hours. Most agreed that someone from the medical group must be available for patients and for active communication with ERs, as a central tenet of their primary care commitment. Larger practices can hire or contract with nurse triage, providing them access to patients’ electronic health records (EHRs), with a physician back-up for difficult cases. A few interviewed physicians take calls 24/7 from their own patients rather than alternating call with others — giving out their personal cell phone numbers; they have found that patients rarely abuse this privilege, knowing that they would be intruding on the physician’s personal life.
Some practices have established formal relationships with urgent care centers and retail clinics as a preferred alternative to ER care, with established procedures for transfer of clinical information. One practice has worked with local hospitals to achieve a “warm hand-off” from both the ER and inpatient services. This permits the hospital to access the practice’s appointment schedule to make a timely patient appointment, thereby obviating the need for a hospitalization or observation stay.
Addressing Continuity During Hospitalizations
As with after-hours care, respondents generally thought ACO clout could help assure better hospital-ambulatory practice communication and collaboration, while also considering that achieving longitudinal continuity was a core duty of primary care physicians.
Most, but not all, of the respondents had given up inpatient activities over the past decade, with some expressing regret that they would not be there to support their patient during the stress of the inpatient stay and provide useful information to the hospital physicians caring for their patient. They basically felt they could not justify the time away from their practice for a relatively small number of patients.
Yet, a number of the interviewed primary care physicians had developed approaches to assuring their presence was accomplished at times when it would be most useful. As one rural-based physician recounted, “I know it is time to go over there because I learned to put the patient in charge.” That is, the patient calls her before the hospital does with a progress report — and then she is able to participate in her patient’s care by phone even when she can’t get there physically. Some thought that in addition to calling, it would be relatively easy to use Skype-like technology to have visual contact during the inpatient stay.
Another practice requires all of its providers to take “phone call hours” from 8:00 to 9:00 each morning. This allows hospitalized patients and their families to call to discuss the course of the hospital stay and identify issues of concern, and to notify the physician when they need to communicate with the responsible hospital physicians. A few of the interviewees assigned their practices’ care manager to monitor inpatient clinical notes available through an EHR shared with their local hospital, or to simply call hospital staff on a daily basis — and to then alert the patient’s physician when an event occurs that a physician would want to be involved in, such as a new cancer diagnosis. These approaches allow the primary care physician to maintain continuity when it’s most important but do not require the physician to have the lead responsibility for the patient’s hospital care.
Medical Home Versus Good Medicine
When we asked whether the PCMH had ignored the traditional tenets of primary care, one interviewee (a health plan’s medical director) responded, “I don’t know how much of that core primary care is medical home versus good medicine.” That comment captures well our concern about how the PCMH is evolving: while the model calls for substantial redesign of primary care—adopting potentially very beneficial approaches, such as population health, team-based care, and the like—it may not adequately address whether good medicine is being practiced inside the medical home.
Admittedly, first movers and early adopters of the PCMH model likely do practice “good medicine,” and their adoption of the model may very well be producing the positive results observed in some studies, while blazing a trail of what the future of primary care could look like. But our interviews suggest that there are practical ways to foster first contact care and continuity that could be adopted by all practices to strengthen their commitment to these two C’s of primary care, at least (approaches to assuring comprehensiveness seem more elusive). Don’t get us wrong — the PCMH model is a great idea; we just think that to be effective it needs to ensure that the traditional tenets of primary care are included.