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Experts Say Medical Homes Are a Work In Progress

So far, there is little data proving the value of the "patient-centered medical home" (PCMH), a new model for primary care that has gained the attention of corporations, health plans, and government officials. Yet public and private payers are mounting demonstration projects across the land; the National Committee on Quality Assurance (NCQA) has already certified 800 physicians as medical homes; and thousands of practices either are or will soon be trying to reengineer themselves to capture some of the financial incentives for becoming medical homes. Meanwhile, President Obama, HHS Secretary Kathleen Sebelius, and a host of lesser lights are suggesting that medical homes should be a major component of healthcare reform.

A new study in the Annals of Family Medicine should be required reading for these policy makers. Although the physician researchers who compiled this study of the American Academy of Family Physicians' TransforMed project won't publish hard data on the pilot until early next year, they said they felt compelled to put out this paper now, before the country veers off in the wrong direction on medical homes.

After evaluating the two-year project in which about three dozen family practices tried to transform themselves into medical homes, the authors said,

"We have already learned enough from [TransforMed] to identify some potentially dangerous red flags fluttering over the [Medicare and health plan] demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure."

Becoming a medical home, the researchers point out, requires practices to remake themselves from the bottom up and necessitates a "continuous, unrelenting process of change--Transformation includes new scheduling and access arrangements, new coordination arrangements with other parts of the health care system, group visits, new ways of bringing evidence to the point of care, quality improvement activities, institution of more point-of-care services, development of team-based care, changes in practice management, new strategies for patient engagement, and multiple new uses of information systems and technology."

In fact, this change is so difficult to accomplish that most of the practices in the AAFP pilot experienced "change fatigue," and none had attained all of their goals within the two-year time frame of the project, which ended in June 2008. Among the toughest challenges for physicians was learning new ways of relating to patients and working with their own staffs.

Additionally, information technology is not quite up to the task, the researchers said. "The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. A function as seemingly simple as a disease registry was either absent from EMR systems or extremely awkward to activate and required complicated workarounds."

Noting that "there is no expert who knows what a PCMH actually looks like," the authors advised the NCQA to revise its qualifications for being recognized as a medical home when more data is available from TransforMed and other demonstration projects. They also asserted that much more money will have to be allocated to help physicians transform their practices than has been suggested so far. And they said that professional organizations will have to shoulder the burden of helping physicians relearn their occupation.

Clearly, the patient-centered medical home has a long way to go before physicians will be able to use it to transform health care.

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