The Wall Street Journal
recently published an article entitled ”.” It sounds discouraging, but we need to understand how the study was constructed. This article is from the February 26, 2014 edition of The Journal of the American Medical Association
(JAMA), and featured a RAND Corporation study of a pilot project in Pennsylvania. The intervention was “Technical assistance, web-based training, creation of disease registries and assistance from coaches trained in practice improvement.”
The targets were asthma in children and diabetes in adults. There was a large financial incentive to participate ($20K per physician, some receiving up to $92,000, if their practice achieved AHRQ certification). Given the narrow nature of the pilot, and the three year measurement time frame, I wasn’t at all surprised the results came out the way they did.
I’m sure it will be used as an example of a failed patient-centered medical home (PCMH), but I don’t think that’s a fair assertion, and I don’t think that was the intent of the authors. One of their comments mentioned this study should show that the U.S. healthcare delivery system shouldn’t assume that the PCMH design is finalized—no disagreement with that assertion.
Based on a careful review of the paper, it seems the study design was more focused on gaining certification than improving care. Focusing on children with asthma and adults with diabetes is not really a PCMH approach, but more of a case management model. I would expect that an outpatient medical practice using PCMH principles would develop registries of its entire population (not just diabetes and asthma), undergo analyses to determine risks within the population the practice is managing, and then develop appropriate interventions based on the risks of the population.
I would certainly expect some patients with diabetes to need additional services. I would also expect a certified diabetes educator (CDE) to work with patients as appropriate to achieve guideline compliance and improved clinical outcomes—and publicly report those outcomes. Group classes might be a feature of the program, and perhaps clinical monitoring using telemedicine.
I would expect similar monitoring for a risk-adjusted group of patients with heart failure, with careful attention to the transitions of care from acute care settings to home monitoring and home visits to prevent relapses back into the hospital.
There are any number of interventions that might be included, but a key principle of the true PCMH model is the use of data to analyze the effectiveness of the program in order to continuously improve the care. I believe this can’t be accomplished in a fee-for-service environment, but needs to be developed in a value-driven model that pays for improved outcomes.
Here’s the bottom line—the current fragmented way in which we care for sick people in the U.S. isn’t serving the best interests of those who need care. Don’t let this RAND Corporation study slow the progress toward achieving patient-centered care. I absolutely believe the model is not finalized, and, to that point, I agree with the authors. We’re not finished, but we can’t stop efforts to achieve The Triple Aim of better outcomes for patients, better health for populations and better cost. Continued development and evaluation of patient centered care is our best option.
Michael L. Taylor, MD, FACP
Chief Medical Officer