Is the PCMH Movement the Solution?

The Patient-Centered Medical Home (PCMH) has been lauded as an innovative approach to improvements in the healthcare system that include reducing cost of care, improving quality of care and the patient experience, and reducing instability in the primary care workforce. Whether those outcomes are actually achieved outside of the theoretical concept remains an open question. Mixed evidence exists based on evaluation of individual PCMH initiatives with differing interventions.

This meta-analysis therefore synthesized the evidence across studies in order to assess changes in costs and use of hospitalization and physician visits, access to screening tests, and measures of successful care for patients with diabetes. Seventeen studies evaluating eleven pilot programs were invited to participate and 100% of the initiative evaluators participated. Each evaluator contributed new estimates based on a standardized set of variables and methods: patient attribution; definitions for measures of utilization, quality, and cost; and impact.

On average, PCMH transformation did not have its intended effects on cost, utilization, or quality. In the full sample, there was an association between the PCMH and two measures: reduced use of specialty visits (by 1.5%) and increased cervical cancer screening (by 1.2%). In a subset of patients with higher comorbidities, there were lower costs of care (by 4.2%) and increased breast screening (by 1.4%). However, these findings were not considered significant due to the heterogeneity across studies.

The US medical system needs innovation that recognizes the range of personal and clinical needs across multiple patient populations as well as the limited resources of both the human workforce and the payment system. The building blocks of PCMH – care coordination, integrated services, tracking and management of chronic conditions and complex patients, wide access to care, and team-base care – stand as independent innovations that differ greatly from the traditional approach to care delivery.

While PCMH is not necessarily the immediate and direct solution to our dysfunctional healthcare system, the building blocks provide room for exploration. Complex transformations of our healthcare system require significant political and financial changes. For now, perhaps finely tuned efforts at the front lines of patient care are sufficient to produce outcomes that may ultimately provide a cumulative impact.

commentary by Kameron Matthews

Abstract

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

PMID: 28264952  Sinaiko, AD, et al. Health Affairs. 2017; 36 (3): 500-508.