The definition from this governmental agency bears little resemblance to the original definition put forward by medical associations in 2007, and known as the Joint Principles of the Patient Centered Medical Home. Just like the term “patient centered”, which was originally defined as a preferred style for the doctor-patient interview, where doctors actively solicit patient opinions and input, and later expanded by Dr. Berwick to include “choice in all matters, without exception” for each patient, but is now used casually in conversation to describe everything from rationing care to cheap, separate and unequal care, the PCMH definition is being devolved by AHRQ to mean a type of communal third world medicine without doctors.
What follows below is my feeble attempt to return to basics, and stop the eager beavers from throwing the baby out with the bathwater just because it’s easier, cheaper and more lucrative to keep the bathtub clean if no babies are present. We will begin with restating the original Joint Principles of the PCMH and continue by looking at the PCMH recognition program derived from these principles by the National Committee for Quality Assurance (NCQA), which is by far the most prevalent recognition program and is considered by most PCMH proponents to be the “gold standard” in this field. Yes, I know you are tempted to dismiss this (or worse), particularly if you are one of the many exhausted and disillusioned docs, considering, or actually fleeing for the closest exit from the hamster wheel known as insurance reimbursed primary care. Nevertheless, it may be in your best interest to read on patiently for the next 2 minutes (or so).
Restatement of the Original (2007) Joint Principles of the PCMH with Commentary
- Personal physician - You can’t argue that you don’t need to build a trusted relationship with your patients over time
- Physician directed medical practice - You can’t argue that doctors should not direct the practice of medicine
- Whole person orientation - You can’t argue that it’s best to concentrate on the disease instead of the patient who has the disease
- Care is coordinated and/or integrated - You can’t argue that how your patients get medical care outside your practice walls is none of your business
- Quality and safety - You can’t argue that you have no obligation to provide high quality care and not harm your patients
- Enhanced access - You can’t argue that your patients don’t need to have adequate access to medical care
- Payment that recognizes the value added - You can most certainly argue that payments for comprehensive primary care should be vastly increased
The patient centered medical home is not a model of care, it’s not a framework, it’s not an idea and it’s not a concept. It’s how doctors practice medicine. And it’s an itemized bill for those who pay for primary care. Well, that’s all fine and dandy, but why do we need certifications and accreditations for something as simple and as natural as breathing in and breathing out? Guess what? You don’t.
NCQA does not certify medical homes and does not offer PCMH accreditation programs. NCQA “recognizes” practices as medical homes. In other words, NCQA looks at what you do, and if you practice according to principles #1 through #6, NCQA will recognize that you do, and the entities that pay for your services should subsequently pay the bill presented in principle #7. NCQA cannot and does not plant itself in your office for six months to observe your practice, so instead, it’s asking you to ship over documented proof that you practice good medicine, and herein lays the problem. First of all, who appointed NCQA as the arbiter of your being a good doctor, or not? Second, who decides what authentic proof of practicing good medicine is? Third, what if you disagree with NCQA’s interpretation of the PCMH principles? And fourth and foremost, why on earth should you have to prove that you are a good doctor?
Let’s take it from the bottom up. Nobody feels compelled to “recognize” good lawyers or good accountants, so why should we recognize good doctors? The answer is exactly what you think it is. We can go through lengthy debates about the evils or merits of health insurance, particularly the public version, versus free-markets, but that would be largely irrelevant here. The fact is that Medicare for example, and private insurance as well, pays the same amounts to outstanding doctors and to the ones that are less so, effectively treating doctors as undifferentiated commodities. Being a gifted diagnostician or a caring and attentive physician, or having years of expertise under your belt, does not bring higher rewards than being careless, uncaring or outright incompetent, and perhaps the opposite is true. Yes, I know that your patient waiting lists are overflowing, but so are the waiting lists of your lesser colleagues, and either way there is no tangible financial benefit to waiting lists.
There are two, and only two, solutions to this quandary: exit the system and offer your services directly to the portion of the public that can pay, or find a systematic way to differentiate excellent physicians, and pay more for their services. In a perfect world, doctors would get together and define excellence, which they did and that’s what the joint principles of the PCMH are, but then would take this one step further and formalize a “differentiation” process, which they stopped short of doing, and complete the task by specifying the monetary value of excellence as a starting point for negotiation with payers, which they never even dreamed of doing. You should not be surprised that the laws of physics apply to physicians, so when a vacuum is created, something will eventually fill it.
NCQA stepped in to formalize the “differentiation” process. You can argue that this or that aspect is incorrect or irrelevant, and NCQA would be the first to tell you that there is plenty of room for improvement, but I would suggest that this is not the real problem here. The real problem is the evaluation of the NCQA program. To evaluate the operationalization of the joint principles of the PCMH, one would most likely go about trying to ascertain if a NCQA recognized practice is indeed practicing according to the joint principles. Does a recognized practice really provide a personal physician for each patient? Do doctors actually direct the care of all patients? Does the physician treat patients as persons, not diseases, making William Osler proud? Does the practice minimize harm to its patients, compared to non-recognized practices? Does it provide enhanced access compared to others? Is the care longitudinally coordinated in the practice? Instead of attempting to answer these questions, all PCMH evaluations are measuring only a portion of principle #5, quality, and quality is being defined by the same faulty measures used by all other “initiatives” that are triple aiming at reducing costs of care. Hence the entire argument is boiled down to one question: does PCMH cut costs for health plans today? To which I would respectfully answer: who cares?
The original joint principles begin by defining the patient centered medical home as follows: “The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” Nowhere does it definitively assert that the PCMH will cut costs of care, let alone “ER utilization” and “preventable readmissions”. Yes, it makes sense to postulate that comprehensive good primary care, other than being good for patients, may provide some secondary benefits to insurers, most likely to materialize in a decade or two, but this hypothesis has never been studied or proven. It is just assumed now. And, more stunningly, the reverse hypothesis is also assumed, i.e. care that immediately lowers expenditures for health plans is by definition of higher quality, with the questionable caveat that it should also include, say, more women getting mammograms.
I would submit that the PCMH movement has reached a fork in the road, and it needs to choose between servicing patients and their doctors by supporting attainment of excellence in primary care practice, and servicing a consumerist economy by defining adequacy of cheaper provider settings. I would also submit that barring purposeful intervention and strong support from the primary care associations, the best meaning PCMH organizations will not be able to sustain the pressure applied by industry stakeholders to morph the PCMH into just another lever for political and financial purposes that have little to do with good medicine. For the AAFP, AAP, AOA, ACP, the opportunity to speak up is here. The time to act is now.