A recent study in Medical Care about Horizon BCBS’s Medical Home pilot reminded me of the expression a “house does not make a home.” Or in this case how building a medical house to the spec (as laid out 3rd parties like NCQA and JACHO) is not the same as building a medical home that is truly patient-centered . As it turns out, researchers involved in the Horizon study claimed not to have found any significant differences between PCMH practices and non-PCMH practices.
Don’t get me wrong, my hat is off to the thousands upon thousands of primary care practices from New Jersey to Hawaii that have put in long hours going the extra mile to become recognized as Patient Centered Medical Homes. Due to the efforts of these first generation PCMH pioneers, and their health plan partners, millions of people now have unprecedented access to primary care physicians providing:
- Physician-led team care
- Electronic records (EMR/Registry)
- Embedded care coordinators
- PHRs and web portals
Yes, many of the PCMH pilots, now into their 4th or 5th year, are showing promising results with reported reductions in ER visits, hospitalizations and 30-day hospital readmissions. These pilots are also reporting improvements in HEDIS-related quality indicators.
But while team care, care coordination and EMRs may increase practice efficiency, there is nothing inherently patient-centered about these “things.”
That’s because patient-centered care is a philosophy of care delivery…not simply a punch list of HIT and staffing requirements. Crossing the Quality Chasm defines patient-centered care as “respectful of and responsive (where practicable) to individual patient preferences, needs, and values”; or as Berwick is quoted as saying, “nothing about me (the patient) without me.” Patient-centered care occurs between people – not things – and manifests itself in the way the clinician and patient talk with and relate to one another, e.g. patient-centered communications.
With all the attention placed on building out the HIT and staffing infrastructure, this first generation of PCMH pilots, with some notable exceptions, has lost sight of the most what makes a medical house and patient-centered medical home – notably the relationship between the patient and the clinician, beginning with the quality of clinicians’ patient-centered communication skills.
Yes, many accredited PCMH’s have patient advisory boards and conduct patient satisfaction surveys. But as researchers like Street and Epstein have suggested, relying just on patients’ impressions and ratings of “patient-centeredness” may provide false reassurance given that many patients have never experienced anything but suboptimal care and physicians that employ a paternalistic, decidedly un-patient-centered style of talking to patients. (Until recently, I myself had never encountered a real patient-centered physician).
As I discussed in an earlier post, the majority of physicians today employ a paternalistic, physician-directed style of communicating with patients. As such, there is no evidence to suggest that the patient communication skills of physicians practicing in accredited PCMHs are any more patient-centered that their counter parts in traditional practices.
Based upon the literature, what is absent in this first generation of PCMH pilots is any serious, systematic attention given to assessing and/or improving the quality of the patient-centered communication skills of physicians and their care teams. This oversight is worth noting since the benefits expected by policy makers and underwriters of PCMHs and ACOs under health care reform have been linked in the research to the strong patient-centered communications and not HIT, team care and care coordinators.
Why Is This Important If PCMH Pilots Are Reporting Positive Outcomes?
The early saving being reported by many PCMH pilots may well represent the “low hanging fruit.” This is not an unreasonable supposition given that most physician practices have never had EMRs, care coordinators, or team care prior to the PCMH pilots. As is so often the case, within a short few years, this low hanging fruit will disappear.
But there is another way. Thirty years of research has demonstrated the benefits of patient-centered communications when it comes to increased productivity, greater patient engagement; better outcomes, lower health care use/cost and superior patient experiences.
Going forward, PCMHs, ACOs and their sponsors will need to look past HIT and team care to the quality of their patient-centered communication skills if they are to assume the role envisioned for them under health care reform.
That’s my opinion…what’s yours?
Note: Later this Summer, Mind the Gap will be announcing the Adopt One! Challenge TM. for physicians and their care teams. The goal of the challenge is to encourage physicians and their care teams to adopt one new patient-centered communication skill within 2014.
Sign-up to learn more about this one-of-a-kind “Challenge”:
Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs
a policy push on patient-centered health care. Health Affairs. 2010;29(8):1489-1495.
Ming Tai-Seale, et al. Recognition as a Patient-Centered Medical Home: Fundamental or Incidental? Annals of Family Medicine. 2013;11:S14-S18.
Street, R., et al. The Values and Value of Patient-Centered
Care. Annals of Family Medicine. 2011;9:100-103.