Saturday, July 2, 2011

Process Centered Medical Home

A new study on Patient Centered Medical Homes has been published in Health Affairs and we have a new, but predictable, indictment against small independent primary care practice. The study authored by Rittenhouse, Casalino, Shortell et all, is descriptively titled “Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes", and follows an earlier 2008 study that surveyed large medical groups.  The study is surveying practices with 1 to 19 physicians, and in a nutshell, small practices, particularly those owned by physicians, are less likely to have medical home processes incorporated in their workflows. On average, the bigger the practice, the more likely it is that medical home processes are used, and the likelihood increases if the practice is owned by a hospital or an HMO. Hardly surprising, but the enlightenment is, as usual, in the details.

The patient centered medical home model is based on the seven joint principles stated by the various primary care associations as follows: personal physician, whole person orientation, physician led care team, coordinated care, quality and safety focus, increased access and payment reform. Both studies quoted above were restricted to measurement of processes indicative of only four out of the seven principles. Personal physician for each patient and whole person orientation were left out, and so was the payment reform principle, although some measures of external incentives in support of medical home processes were considered.

The existence of physician led care teams was ascertained based on the existence of “a group of physicians and other staff who meet with each other regularly to discuss the care of a defined group of patients and who share responsibility for their care”. Not sure why, but solo and 2 doc practices were not even asked this particular question.

Care coordination was measured through the use of electronic medical records, electronic prescribing, and electronic access to notes from specialists, hospitals and emergency departments, use of registries and existence of nurse care managers. Small practices scored badly on all except electronic receipt of external documentation. It seems that even without EHRs, they somehow manage to get the information needed for proper transitions of care.

Quality and safety were measured by several process improvement methodology questions and typical quality of care measures. Small practices showed measly participation in quality improvement collaboratives and had almost no “Rapid-cycle quality improvement strategy” (no idea what that is and I bet few if any survey respondents did either). Solo and two doc practices were not very good at collecting data from their EHR and scored poorly on use of clinical decision support. However, they held their own when it came to providing physicians with feedback and provided patient education as well as the big boys. They were also par for the course on sending patient reminders. The major “surprise”, noted by the study authors, was how much better those tiny practices were at incorporating patient feedback and generally listening to patients. The 1 -2 docs scores in this sole patient-centered category surveyed, were twice as large as the largest practices, across the board, hands down, no contest.

Finally increased access was measured by availability of group visits and email exchange with patients. Not sure why group visits was chosen instead of same-day access and afterhours access, and as you would expect solo practices don’t do too many group visits. But, lo and behold, they are excellent at emailing patients - a full order of magnitude better than large practices.

By aggregating all survey responses, the study concludes that only 21.7% of medical home processes are used amongst practices of 1 to 19 physicians, with the 1-2 doctors segment lagging at only 18.6%, the 13 -19 group exhibiting a respectable 32.7% and the rest somewhere in between. Since the results are presented in a slightly different manner, it is a bit hard to compare these small to medium practices to the large medical groups surveyed in 2008, but it seems that there too, the largest of practices were more likely to implement more medical home processes with the possible exception of listening to patients, which came in lower than anything in the new survey. The authors suggest that one could look at these results “as a glass one-fifth full, or four-fifths empty”, depending on one’s level of optimism. I would like to suggest a different perspective on this particular glass.

The biggest concern regarding both studies must be the omission of the first and most important principles of the patient-centered medical home: the personal physician for each patient and the whole person orientation. While I do understand the difficulty in measuring the latter, it is pretty straightforward to survey and measure the former. The only two measures in this survey that are indicative of how patients are viewed and treated (minding patient feedback and email with patients) show clear advantages to the independent solo and two physicians practice. I would add that by definition, a solo practice should score around 100% on the personal physician rubric. And as the authors noted in their 2008 article “although infrastructure components are important to ensuring that care is coordinated, integrated, safe, of high quality, and accessible, at the heart of the PCMH is the personal physician and a team of professionals providing first-contact, continuous, and comprehensive care. This focus on primary care adds a qualitatively different dimension to the model. From the patient’s perspective, a medical home is not simply a combination of disease registries, reminder systems, and performance measurement. A medical home is a familiar place, with familiar people, that delivers high-quality, well-organized care that is accessible in time of need”.

So perhaps a more accurate conclusion for this study would be that larger practices, particularly those owned by hospitals and HMOs, are better at implementing processes, while smaller practices, particularly independent ones, are better at patient centeredness. Of course, it should ultimately be up to patients to decide between process orientation and patient orientation.


  1. Well the Principles of the PCMH came out in 2007 and we already have 42,000 docs certified by NCQA states or on there way by July 2011. This study was from a survey done between 2007 and 2009. In Maryland and Michigan with support of the state and HC plans over half the small docs are on board. So given it was a survey that started at the same time the principles came out looks like a glass on it way to being full to me. Small practices are stepping up all over the country but they need support from Medicare, Medicaid and the other payers.

  2. I agree, Paul. I think small practices have the nebulous patient-centered piece pretty much done, but they do need a lot of help with the process part, both organizational and financial.
    I am also seeing PCMH projects cropping up where I live and although there seems to be initial support for participants, I'm not certain what happens after the project is over. The customary few dollars per patient per month are not nearly enough.