Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

Getting to a PCMH may be a short stretch for an office with sufficient resources along with a patient centered culture to begin with. I already have advanced EMR capabilities, the office is very much run in a team approach. It's very easy to track appointment histories, referrals, no shows, health maintenance schedules, prescribing patterns (including when meds are due and last seen), plus results of all labs and testing are given by mail or phone. All staff are tuned into tracking these parameters, and we meet regularly to discuss glitches. Access is not a problem (we stay until the last patient is seen, even it means overtime for staff), and all calls are returned the same day (we can't do forms and letters that quickly however). To me, what really remains is proving we're doing this stuff, and getting our NCQA Certification. It won't take two years.

Competing interests:   None declared

Forget about the current crop of EMR's and start with a paper system until the technology catches up with the idea.

Each person brings a unique personality to the table and a closet full of emotional skeletons and past wrongs perceived or otherwise. If a person cannot adapt to change readily and many cannot, the whole project will fail.

Some practice partners may need to go their separate ways, especially if the partnership was shaky to begin with.

Once a physician is trained, he will not stray far from the way he was taught. That's evident in the problems that are being encountered. Making the theory of the patient-centered medical home a part of medical school training will eventually eliminate these problems of adaptation.

If these clinics are going to remain viable, the idea of the physician as all knowing and all powerful will have to be cast aside. The physician will have to embrace collaboration and open communication with all of the team members including the patient.

The physician can't get angry or insulted if the patient has discovered through their own research a new and promising treatment for what ails them. Patients now have access to a wealth of information via the WWWeb, some of it valid and some of it pure quackery.

As a registered nurse, I tell my patients to definitely use the Internet to get answers but to stay away from .com sites because the "com" stands for commercial, which means they are trying to sell you something, whether it's the latest treatment for prostate enlargement or a totally bogus supplement. I instruct them to stay within the domains of .edu and .org because the information on these sites has usually been peer reviewed by medical experts.

You cannot make a person embrace change. You can only lead them to it. How they react and adapt to it is THEIR problem, not yours. If they cannot adapt, they will be left behind.

Competing interests:   None declared

Nutting and his colleagues have put forth a rather useful guide for medical practices and groups motivated to “transform” themselves into Patient-Centered Medical Homes (PCMH). I would call attention to their very sage kernel of caution contained in the first paragraph, “…the rush to demonstrate operational and financial feasibility...risks premature closure of the larger PCMH conversation and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs.”

Frequently demonstration projects are focused and concerned with implementation and logistical matters of putting into place what was proposed. While these lessons learned are helpful, the article highlights the need for the “movement” to pay attention to a few other key activities: defining PCMH and subsequently developing a program theory. The PCMH model has good face validity; however, developing consensus of PCMH definition seems to continue to elude us. What are the key and critical components of PCMH? What distinguishes practices as PCMHs? The typical response of “you know one when you see one” handicaps replication and evaluation of successful PCMHs.

Moreover, a model that links PCMH components, processes, and intended outcomes together does not exist. PCMH is an excellent projective technique that allows us to implicate our favorite output or outcome for practices, doctors, or patients. However, when sharing these perceptions among others, it is clear that there is no consensus around the causal linkages between implementing various PCMH components and outcomes at various levels. We need to be able to identify which of the key components of PCMH have the most potency and impact on patient outcomes. I believe that we are onto something that could significantly change patient care and outcomes but we may miss it.

Competing interests:   None declared

Participation in the TransforMed National Demonstration Project has been an honor and we learned a great deal from the facilitators and the other practices. However, at the end of the day, we are still waiting for our payers to value even ONE these wonderful patient-centered, value-added services. As I said on day 1, "show me the money!" It has become increasingly clear that every system is "payer centric" and thus the only way to have truly "patient-centered" care is to eliminate the middle man and work directly for the patient who is the arbiter of value and quality.

The way we are currenly paid is the equivalent of every restaurant getting $8 per meal (and spending 8-10 cents on the dollar to collect it). Is it any wonder the "dining" experience is suffering? Pay per performance is the equivalent of every restaurant getting paid based on their grocery list. This nibbles at the edges of "quality" but will never get there. The PCMH as it is currently envisioned, is the equivalent of every restaurant redesigning their kitchens and processes for the hope of someday, maybe, getting $12 per meal. Will your "dining" experience really improve?

I suggest that a free-market, where insurance provides a defined benefit to the patient to subsidize their care but were providers of non-exigent care can charge what the market will bear for their services, is the only way we will ever see truly "patient-centered" care and a vast array of innovative care models. Time to escape the one-sized fits all "Bell Telephone model" that clearly discourages innovation, quality, technology, and service and develop a true free market with multiple options for patients and providers.

Competing interests:   None declared

This is an important and timely article. Think of it as a counterpart to a “data safety monitoring committee” warning, issued in a standard clinical trial, warning of potential safety issues. As one of the first primary care medical home demonstration projects, the National Demonstration Project is being eagerly watched. Physicians and policy makers should be anxious to hear how realistic the proposed practice changes were, and how successful the practices were in transforming themselves into so called “medical homes.”

The warning message from this thoughtful and intimate evaluation—both qualitative and quantitative—is that transformation is not easy, and changes are considerably more difficult and take significantly longer than even cautious proponents of the PCMH model expected. From EMRs that were not easy to implement and use, to new scheduling paradigms, to staffing and role turnovers and conflicts, to leadership and change management, to overcoming reimbursement inadequacies, even heavily coached and supported practices found the transformation to be challenging. While this does not bode well for PCMH as a quick fix others can readily copy and implement, it serves as a constructive wake-up call to the PCMH movement to take seriously the myriad of issues this report raises. It also suggests to me that unless many of the larger dysfunctionalities of the way health care is organized and financed are addressed, building a system that is truly friendly to primary care, such as exists in many countries outside the US, the PCMH movement will continue to be swimming upstream. (1-5)

The authors describe how EMR technology foundered on the shoals of practice work and redesign. They give a glimpse into the frustrations faced by practitioners trying to make the current generation of ambulatory EMRs serve both as efficient ways to carry out traditional process that may have worked to their satisfaction on paper, as was as serving as the infrastructure and engine for driving transformation. They are right to question the readiness of current systems for efficient documentation and work flow facilitation, (leading some to question whether requiring electronic records is either necessary or a fair criteria for NCQA PCMH certification). This superficial truth, that EMRs may not be sufficiently mature to unqualifiedly recommend and easily implement, should not obscure a larger truth—that to scale the heights of radical practice change, a new generation of EMRs are needed that made work and change radically easier.

1. Schiff GD and Young QD. You can't leap a chasm in two jumps: The Institute of Medicine health care quality report. Public Health Rep. 2001 Sep–Oct; 116(5): 396–403.
2. Starfield, B. Access, Primary Care, and the Medical Home: Rights of Passage Medical Care: October 2008 - Volume 46 - Issue 10 - pp 1015-1016
3. Himmelstein DU, Warren E, Thorne D, et al. Illness and injury as contributors to bankruptcy. Health Aff (Millwood). Suppl Web Exclusives: W5-63–W5-73:W5.
4. Uhrig JD, Bann CM, McCormack LA, et al. Beneficiary knowledge of original Medicare and Medicare managed care. Med Care. 2006;44: 1020–1029.
5. Hart JT. The Political Economy of Health Care. A Clinical Perspective. Bristol, United Kingdom: The Policy Press, 2006.

Competing interests:   None declared

Dr. Nutting and his co-writers have done an excellent job delineating the lessons learned, recommendations for policy and warnings. Unfortunately, some people are focusing on the negatives instead of seeing what actually was accomplished and what will be accomplished in the future. One of the most pertinent findings of the National Demonstration Project was that 2 years is not long enough to see the benefits of breakthrough change.

Our practice (a 4 physician practice in middle Tennessee) entered the demonstration project with a 6 year head start on the practice of the future: we had implemented an EHR in 2000, started serious work on quality improvement in 2003 and begun patient web communication and Evisits in 2005. Our experience was that it took about 2 years to fully reap the benefits of an EHR financially and several years longer to see marked improvements in quality. We were able to cut back on full time employees by 1 ½ per physician and our quality went from the 50th percentile to well above the 90th percentile. Insurance reports confirm that our patients cost them less and that our quality is significantly higher than average. Patients are healthier and we’ve saved money, both for ourselves and the system. Bottom line is: important change occurred but it took longer than 2 years. We continue to work on our vision of providing a patient-centered medical home. Our focus now is to work on the “patient-centered” part of the home- keeping what patients want and their overall satisfaction at the hub of our decision-making processes.

Our healthcare system is broken. There is great potential for both huge savings and improved population health if the PCMH is implemented by the majority of primary practices, as demonstrated by our practice. Demonstration projects can help point us in the right direction, but if the wrong conclusions are reached, society could miss out on an important opportunity to help people live longer, more productive lives. Dr. Nutting has pointed out the difficulties, along with the advantages of developing a patient-centered medical home. My hope is that the majority of physicians will focus on the advantages and begin their own transformations processes.

Competing interests:   None declared

Paul Nutting and colleagues write cogently about the long, developmental process required for practices to redesign themselves. Too often we gravitate toward quick-fix carve-out programs to deliver us from healthcare’s fragmented payment and delivery systems. The recent failure of Medicare’s care coordination demonstration is but the latest evidence in a string of vendor-based disease management and electronic interventions to overpromise and under-deliver.*

To achieve real improvement in quality of care, we will need both macro-level payment reform and micro-level care delivery transformation. Yet, how to transform care delivery along the promising lines of the patient centered medical home remains unclear. Nutting and colleagues write that because of the size and complexity of the medical home concept we should be wary of production models (e.g. Lean) and consecutive PDSA cycles (Model for Improvement) as means to achieve transformation. But how teams change is an empirical question, one that's answer depends on site context. Toward that end, two demonstrations that I will be watching as they systematically asses how to redesign primary care are:

1) Group Health’s Medical Home demonstration. Piloted in one site and systematically implemented across 26 others, this initiative should show if and how an integrated delivery system is able to rapidly spread those elements of the medical home demonstrated to improve health outcomes, patient and provider experience.

2) Qualis Health’s “Transforming Safety-Net Clinics into Patient Centered Medical Homes” initiative funded by the Commonwealth Fund. This four year project will work with more than 65 Fee for Service safety-net practices in five states to support practice redesign using practice coaching and a shared learning community.

To build the core capacities of a learning organization we need to reject the snake oil of quick fixes and get real about engaging teams to re-imagine and redesign care.

*Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials Peikes D.; Chen A.; Schore J; et al. JAMA. 2009. 301(6):603-618

Evidence for the effect ofdisease management: is $1 billion a year a good investment? Mattke S, Seid M, Ma S. Am J Manag Care. 2007 Apr;10(2): 91-100.

Costs and benefits of health information technology. Shekelle PG, Morton SC, Keeler EB. Evid Rep Techno Assess. 2006 Apr;(132):1-71.

Competing interests:   None declared

I’m delighted that Nutting et al felt “compelled to share early lessons” of the National Demonstration Project (NDP) on practice transformation to a Patient-Centered Medical Home (PCMH) and can hardly wait for the “more-exhaustive mixed methods research reports planned for early next year”. With an article as rich in ideas as this one, it is tempting to comment on every point; but I’d like to focus on just a couple.

First, in discussing the interdependence of the components of a PCMH, Nutting et al observe that “the PCMH should be designed to enhance the patient experience”. I fear it is easy to ignore this potential beacon to help guide practices and practitioners through the complicated thicket of interdependent components needed to achieve transformation to a PCMH. Wondering about, measuring, and responding to what patients are experiencing should be at the center of all efforts to become a PCMH. Otherwise, its not really “PC”, is it? Yet, at the moment there is no standard set of patient experience measures required of practices to qualify for NCQA recognition let alone a set of patient experience measurement tools that would help practitioners get detailed feedback from patients about various components of the PCMH that they implement. That, however, should not be a cause for inaction: Twenty-five years ago I designed a survey instrument for patients at a large multi-specialty group practice, and while it might have been a better or more informed set of questions, it still provided patient experience information that was extremely useful in understanding patient needs for appointment scheduling and how those interacted with the overall experience with the practice and physician as well as providing information about specific characteristics about patients’ experience with the physician and other members of the practice team. So, I would urge readers not to be daunted by the early findings of the NDP indicating complexity in the transformation process but rather to consider beginning by dissecting and understanding experiences of patients in your own practices and using those to guide you, indeed support you, on the transformational journey.

Second, the early findings about the difficulties in getting “plug and play” technology for the PCMH are disturbing but not surprising. I fear that many of the efforts to develop EMRs in this country have been influenced by “techies”, even by physician-techies. They can end up providing “glitzy” screens that the techies can navigate at blinding speed, but often don’t provide or make it difficult to use functions that would be helpful to the practitioner and patient such as the example of disease registries given in the article. In countries that have much greater EMR use than the U.S. and where physicians find them indispensable, the systems are not necessarily fancy-looking, but they have functionalities that appreciated greatly by their users. In Denmark, for example, where physicians all buy their own EMR, it is easy to generate simple tallies of practice activity that translate into fee-for- service billing that in turn leads to physicians being compensated not only for face-to-face visits but email and telephone encounters. The government does support a national information exchange that enables the easy transfer of the practice activity, but also facilitates e- prescribing, timely reports of activity from consultants – whose own compensation is dependent upon filing such reports, and timely reports of interactions by patients with the organized “off-hours” services. Physicians find these functionalities not just desirable but essential for their practices, and patients feel supported 24/7. It is good news that in the U.S. increasing attention is being paid to health information technology. We all, individually and organizationally, need to advocate for systems that are affordable, highly functional, and easily usable by practitioners and patients.

Competing interests:   None declared

This is really important work that needs to be disseminated to every practice thinking about or doing a medical home. I am amazed it did not receive more attention in the health care press.

Regarding technology, as a vendor of software to support a medical home and quality improvement, I am struck the approach of many prospects in evaluating technology that I hope does not reflect an overall approach to PCMH. When we discuss software requirements, many practices pull out their medical home certification checklist and ask us to detail what “rows” we fit. There is no context to the discussion. They ask “Do you have a patient portal or don’t you?” instead of, “we’d like to electronically communicate with our patients, how can your solution facilitate that?” or they ask “can you track three clinically important conditions, as our checklist calls for?” instead of thinking comprehensively like “do you comprehensively track all patient problems, how do you code these problems and how do you get around the issues of billing data?”.

This “robotic” response to the rows scares me. This isn’t what a medical home is about at all. I am a huge proponent of Recommendation #2 – Tailor the Approach to the Practice. A practice has its own unique characteristics that have to be respected and drawn upon. Running down “the checklist” doesn’t do that. This medical home needs to fit the DNA of the practice.

Second, many that have not yet started their medical home transformation can only imagine their technology needs in the context of how their practice currently operates, not in the context of how their practice will operate after transformation. While that’s certainly understandable, it needs to be said that some transformation needs to occur before technology is selected. Practices need to understand how they will operate after their medical home transformation before shopping for a technology solution. They need the context. Otherwise, they won’t know what questions to ask, won’t be able to evaluate against this context and might buy something that certainly can support a medical home but doesn’t work for them. No one wins when this happens.

I believe if we can get through the hurdles, the medical home presents a wonderful opportunity for primary care medicine. We just need to make sure we do this right. This paper provides wonderful insights into how we need to approach this work.

Competing interests:   None declared

My thanks to the authors and commentators.

Ken Terry's response to this report (http://industry.bnet.com/healthcare/1000649/) as noted by Dr. Grundy, may incite distracting and unfortunate misinterpretations, but overall, Terry's message didn't go off the rails until the last half of the last sentence, i.e. "Clearly, the patient centered medical home has a long way to go before physicians will be able to use it to transform health care."

Yes, PCMH has a long way to go-- before it is FULLY DEPLOYED TO EVERYONE'S BENEFIT. However, the PCMH has already propelled most states and many clinicians to use its principles and version 1.0 measures to transform health care. The pioneers are making progress, sufficient to learn what it takes, take corrective actions, and benefit from this preliminary report's admonitions. This evaluation and these immediate responses to it are objective evidence that much is being learned.

The heads up about the size and scope of the challenge and mid-stride reality check and suggestions, e.g. to incorporate measures of comprehensiveness and relationship essential to primary care--should be welcomed and acted upon. These are not messages of dispair, but rather of progressive leadership toward necessary and worthy ends. Afterall, what is underway is the remake of the largest platform of formal health care delivery in the nation, a foundational component of a US sub-economy that exceeds in size the entire national economies of all but 5 nations. It will take some time to steer this ship to its destination.

No one should misconstrue the message of this timely report. Everyone should exhale, take a deep breath, and keep going. The "PCMH Genie" is out of the bottle and it's not going back in, thank goodness!

Competing interests:   None declared

As one of the TransforMed NDP practices I applaud the efforts of Nutting et. al. to describe preliminary outcomes of the project. Let's not lose sight of the fact that although transformation is difficult, it is doable. At the end of the 2 years, there was cumulatively great transformation. For example, all but 2 of the practices were operating with EMR's, one of the most challenging of projects. All practices implemented at least several new transformative activitities and the comments on our list serve provided not only an informal tracking of our collective progress but also a plentiful roadmap of activities and practical suggestions. The process of practice transformation does not have a discreet ending but must be a continuous process.The ending certainly cannot be receiving NCQA recognition, as Greg Pawlson points out. Although the process is continuous, significant strides can be accomplished in a 2-3 year period and we all have to begin the journey somewhere.

Although the basic "thinking inside the box" activities of basic practice management created modest improvements and there is potential for more improvement and although getting our collective houses in order is essential, those who think that the improved financial performance from basic practice management will fund practice transformation to true medical homes capable of driving improved outcomes, I believe, are overestimating the savings and underestimating the true costs of creating medical homes. I say that while acknowledging that tools such as EMRs, when properly implemented do pay for themselves.

As someone who has devoted significant time and effort to educate physicians about the need to engage in practice transformation and move toward medical homes, I can reasonably state that the physicians in the NDP represent true early adopters and there is more skepticism among the general population of practicing primary care physicians. To get wide scale change there needs to be a priming of the pump in terms of up front payments or at the very least a clear path toward meaningful improved financial performance. Practices will not engage in wide scale transformation unless there is a clear and definite financial case to be made in addition to the clinical case. Just like any human change management process the WIIFMs (what's in it for me) need to be addressed.

Finally, there is another reason for a priming of the pump with up front payment for structure and process enhancement. The Donabedian model of needing structure as a foundation before laying on process improvement in order to get outcomes holds true today. If there is not up front requirements with the associated payments for key structural elements such as care coordinators, IT infrastructure etc. and then support in implementing key supporing processes (eg group visits, care coordination, team huddles) then the medical home pilots will not look much different from the existing pay for performance programs (just with different nomenclature) and those programs have had minimal impact just as Donabedian would have predicted. We must move toward outcomes based justification and payments but not without the necessary structure and processes

Competing interests:   None declared

We appreciate the heads up by Dr. Paul Grundy that our early report (1) from the evaluation of the National Demonstration Project (NDP) is being misinterpreted in the current and fierce policy debate on healthcare reform. It seems that some are taking text out of context to suggest that we are reporting that the patient-centered medical home (PCMH) doesn’t work. This is not the case; our report does provide lessons on the implementation of the PCMH.

We already have abundant evidence (2) that healthcare systems based on primary care yield healthier populations, at lower cost, and with less inequality in health. The PCMH brings together this fundamental value of primary care with the latest learning about how high value healthcare can be organized on its front lines, as part of an integrated system of care. The PCMH is where a lot of the desperately needed personalization, integration and prioritization of care can happen. (3)

The NDP and many other PCMH demonstrations going on now will give us ‘how to’ evidence on accomplishing this value. But we need to set up the correct initial enabling policy conditions now. The findings of the first national demonstration (the NDP)(1) and related contextual data can guide us in developing a system that truly enables the value of primary care and of its manifestation in the PCMH.

The early policy lessons from this demonstration, (1) (the real lessons based on rigorous analysis, not the recent misrepresentations of these lessons) are:

• The PCMH movement is not just blowing smoke. The changes required of even highly motivated, well-supported practices becoming PCMHs are truly transformative!

• True transformation takes time and resources, but if we want healthcare to really be different from the current dysfunction, transforming primary care and building the larger system on this foundation is what will be required.

• President Obama has talked about the need to take a long-term perspective, even as we work on the immediate steps. The analysis by our team (1) supports taking immediate action but with a longer term perspective on what it takes to make truly transformative change.

• After devaluing the primary care function for the past decade, (4) we now need to reinvest in helping it to build itself as the foundation of a high value, accessible, personalized health care system.

• It is likely that we will see more of the kind of misrepresentation that we saw in those distorting the our recent report, as those who have profited from the system dysfunction realize that resources will need to be shifted away from them and toward building up the primary care function that is fundamental and essential to a functional, high value health care system focused on fostering health for all rather than on creating wealth for some.

The grounded lessons in our initial report (1) can help to keep us from going along with the misguided metrics being applied to many of the current demonstrations. Some of these demonstrations are set up to expect cost saving and improved health in a 6-12 month time frame. This time frame is nonsense, if we are talking about true transformation. We need to set realistic expectations. Primary care is what is needed. The PCMH can be a useful manifestation of the primary care function. But we need to put resources into this foundation for the health care system. The political challenges are that to create value for all, some of the current profiteers will lose, and things may look worse before they get better. We need to keep seeking the kind of real, grounded information that the AAFP and the Commonwealth Fund and others wisely supported in their scientific evaluations of the early demonstrations.

Now is the time to invest in primary care as the basis of a high value healthcare system. Our initial report on the NDP begins to show how that might be accomplished.

1. Nutting PA, Miller WL, Crabtree BF, Jaén CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;254-260. http://www.annfammed.org/cgi/content/full/7/3/254
2. Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.
3. Stange KC. The generalist approach. Ann Fam Med. 2009;7(3):198- 203. http://www.annfammed.org/cgi/content/full/7/3/198
4. Stange KC. The problem of fragmentation. Ann Fam Med. 2009;7(2):100- 103. http://www.annfammed.org/cgi/content/full/7/2/100

Competing interests:   None declared

Nutting et.al. have produced a thought provoking appraisal of the initial lessons learned from the NDP. As a participating physician from one of the 36 NDP practices, I concur with their lessons, recommendations and warnings. The report leaves me wondering whether we will ever reach the tipping point for PCMH to take its rightful place in American medicine.

A lot of inertia holds this great concept back. The illusiveness of a brand identity for PCMH impedes promotion. Researchers question the value of PCMH. Overworked primary care physicians lack time, energy and financial incentives to try it. Insurers worry of its effects on their profits. PCMH pilots may be too brief to demonstrate value.

Anecdotal evidence proves little, but my biased testimony of spending the past 4 years of my 30 year career building a PCMH leaves me with no doubt that PCMH is an essential step to rescue medical care and make primary care a desirable specialty again: one in which we can once again not only treat our patients, but care for them too.

America can do so much better medically for our people. Epic policy decisions are about to be made. Though not yet overwhelming, sufficient evidence exists that PCMH takes us in the right direction. If for no other reasons than running out of time, money, and options, we must reach the point as a society where we say “whatever it takes, we will make PCMH work.” Physicians are resourceful. If they perceive that kind of commitment accompanied by financial and logistical resources, they will implement PCMH.

Competing interests:   None declared

I am delighted to see the initial report of the first TransforMED demonstration project. I knew the results were modest with respect to practice transformation. Process change in practice is very hard work, especially when there is not an imperative to change and major incentives are not place. These practices embarked on change because they knew is was the right thing to do.

The authors, charged with evaluating the project, help all of us by not only analyzing what happened and why, but also by providing wide ranging recommendations to guide the future. The take home messages here include how hard the work is and the reality of change fatigue. The recommendations are timely as health policy in Washington is promoting the PCMH as the vehicle for improving primary care. It is important to note that this demonstration project started before the Joint Principles of the Patient-Centered Medical Home were published.

Early demonstration projects point the way for later change, when that change becomes an imperative with incentives in place. That appears to be happening, and I thank the authors for providing such astute recommendations to guide both policy and practice.

Competing interests:   None declared

Good article but seems to be misunderstood – by the press and policymakers

I noted with some interested that this article about the value of PCMH and the report of the national demonstration project of TransforMED has been captured by the press and in conversations in Washington completely wrong. Clearly, your paper is either not understood or being being quoted out of context.

http://industry.bnet.com/healthcare/1000649/experts-say-medical-homes -are-a-work-in-progress/

Competing interests:   None declared

The recent article by Nutting and his colleague is a very important contribution to the growing literature on primary care practice transformation related to the Patient-Centered Medical Home. Indeed, in a recently completed demonstration project focused on helping small practices implement quality improvement projects aimed at improving culturally and linguistically appropriate services led by one of us (SS), we found many of the same problems and barriers noted by Nutting. It is very clear to us at least, that the current PCMH formulation will require substantial changes in practice systems, attitudes and framework for most practices, and that successful implementation of the PCMH requires not only changes in reimbursement but also as the authors indicate, a sustained and substantial effort at practice support, such as that offered in the Practice Transformation project. While we are in strong agreement with the overall conclusions and formulations of the article, we would like to offer the following information related to the use of the NCQA qualification tool being used in some PCMH demonstration projects.

1. NCQA’s Physician Practice Connections® – Patient-Centered Medical Home™ Physician Recognition program was created in close cooperation of an expert panels drawn primarily from the four primary care related medical specialty groups (AAFP, AAP, ACP and AOA) that created the PCMH charter. While some of those groups, as well as NQF, have endorsed the PPC - PCMH for use in PCMH demonstration projects, NCQA has stressed from the outset that the PPC-PCMH does NOT define the PCMH. Furthermore, we are encouraging demonstration projects to use a broad array of evaluation tools and to experiment with aspects of the PCMH that are not yet captured within the PPC-PCMH. Rather we see the PPC-PCMH as a way of measuring the progress of a practice against the elements of the PCMH for which our expert panel and testing indicated that we COULD provide valid and reliable measures or standards. We agree that there are things that are worth doing which at least thus far we have not found a way to measure across practices with reasonable reliability and accuracy. However, the absence of ANY standardized metrics related to conceptualization of the PCMH would, we feel, have created a situation where virtually anything in practice change could be labeled a PCMH project. While no one wants to cut off continued innovation, given that purchasers and in the CMS demonstration, the federal government had committed to pay practices for “being” PCMH’s, it is hard to know how that payment would proceed in the absence of any standards.

2. The authors have omitted references to a number of articles published by Leif Solberg and his research team at HPRF in Minnesota, who, working with NCQA researchers, have reported on testing and evaluation of the PPC-PCMH tool in relationship and higher quality of care in the practice. Beyond these previously published peer reviewed articles, NCQA, again in collaboration with a research team at HPRF, and others are working on additional papers which examine the relationship between scores on the PPC and lower resource use-cost. While there have been no RCT’s as yet published related to the PCMH itself, (which is one of the reasons for the multiplicity of demonstration projects), there are elements that are part of the PPC that have (for example, an RCT of quality measurement, feedback and benchmarking (8) and underpinned by a rich literature on the chronic care model (www.improvingchronicillnesscare.org) and by the work of Barbara Starfield and others on primary care.

3. There seemed to be a misconception that because the PPC-PCMH recognition-qualification is valid for three years, that somehow the practice transformation has to be complete within that time frame. While some demonstrations have imposed what we and Nutting et call feel are very unrealistic timelines (some must be 18 months or two years), there are NO time limits placed on practices to reach level one- or any other levels of the PPC-PCMH program. Indeed we are in strong agreement with Nutting that the process in most practices will take two years or more to even come close to reaching full potential.

4. Perhaps most importantly, from the outset, NCQA has been committed to revising and improving the PPC-PCMH, based on empiric findings from early PCMH and PCMH-like demonstration projects like the one done by Nutting et al as well as on further testing and evaluation of measures that are reliable and valid. Since the PPC-PCMH was launched in January 2008, we have continued to gather information from the field- and have conducted research, under sponsorship from the Commonwealth Fund, specifically on strengthening the “patient centered” aspects of the PCMH. Finally, NCQA has recently laid out a detailed process for creating a new version of the PPC-PCMH lead by an expert panel of key stakeholders including leaders of some of the existing demonstration projects and primary care societies. NCQA is currently seeking suggestions on changes and additions that should f be considered in the next version of the PPC PCMH. We will be convening an advisory panel to guide the updating of the PPC PCMH late this year. We will develop and test the new version next year and we expect to have a new version ready for applications in January 2011. National Committee for Quality Assurance. Technical Assistance Project: Caring for Diverse Populations. Final Report submitted to The California Endowment. August 2008

Solberg LI, Asche SE, Pawlson LG, Scholle SH, Shih SC. Practice Systems are Associated with High Quality Care for Diabetes Am J Managed Care, 2008 Feb;14(2):85-92.
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Competing interests:   I am the Executive Vice President of NCQA

Nutting et. al. have done a tremendous service to all of us who are transitioning our practices, our staff and our patients to a medical home model. These efforts require the energies of physicians, nurses, office staff and patients making the changes so complex and the variables so numerous that rigourous evaluations of process are rare. We should be able to measure outcomes such as lower HbA1c levels and blood pressures but these are often surogates for what really matters to patients, doctors and insurers. Soon it is likely that many of these outcomes will be published and available to the public. When this happens we all will be seaking the insights provided by this process evaluation.

Competing interests:   None declared