Like others working at the intersection of public health and medicine, my faith in primary care has long been unshakeable. Increasingly actualized as the Patient-Centered Medical Home (PCMH), primary care has experienced a decade plus of attention thanks to efforts at retooling and rebranding the field. But in the last week, a tiny crack formed in that faith, with the publication of a new study that showed little impact of a new high-value primary care model. That is, an approach that enhances parts of the PCMH that experts think are most valuable.
A new streamlined recipe for primary care
The article by researchers Colasurdo, Pizzimenti, Singh and colleagues, was published in the February issue of Medical Care. The study was a randomized-controlled trial tweaking primary care practices to emphasize just the highest-value components of a PCMH.
Like simplifying a recipe to its most essential ingredients, the researchers aimed to extract the best patient care and the most cost-savings from more streamlined primary care practices. The practices could choose among 12 high-value strategies to emphasize, and all of which are part of the general PCMH model. These included:
- Offering better access to care outside of usual business hours. People don’t just get sick during business hours. And if their primary care provider is closed, patients will go to more expensive urgent care. Or more commonly, they will go to the ED.
- Generating lists of patients to send reminders about needed care. So few doctors reach out to remind their patients to get flu shots, mammograms and other preventive services. It is part of the reason that only about half the U.S. population gets a flu shot each year.
- Offering coordination of care to high-risk patients. Coordination of care involves helping patients connect with specialists and other needed care. It also means helping patients to make sense those visits, and that may be primary care’s magic bullet.
Challenges to the gospel of primary care
After a year of intervention, the researchers anticipated finding improvements in patient care in the streamlined practices. They did, and they published those results earlier in Medical Care. In this analysis, however, they expected to see fewer emergency department (ED) visits and hospitalizations, and lower costs. But here, they found almost no improvements at all. In fact, they found more ED visits in the streamlined primary care model relative to the control.
For those who know the “gospel” that better primary care means lower costs of care, the findings of this article were worrisome. Decades of high quality research have shown that health care systems that emphasize primary care cost less and have better outcomes [pdf] . But the sheer number of challenges to the delivery of primary care have never seemed greater. The growth of minute-clinics (like those in CVS), the rise of telemedicine, growing numbers of people with chronic conditions, and provider shortages all threaten the field. Given that, there is reason to wonder if these results would hold forever.
Does high-value PCMH matter more than just simple PCMH?
This study considers whether investments in such high value aspects of PCMH are worthwhile. But it is important to note that the study control group was uniquely made up of clinics pursuing PCMH attributes generally. As a result, the question is not so much whether high-value PCMH matters, but instead whether it matters more than embracing the principles of a PCMH generally?
Still, this study has shaken me. Why wouldn’t more emphasis on such high-value ingredients in the PCMH have a clear impact on costs? In fact, researchers, including me, have sought for many years to figure out what matters most in primary care. And since primary care practices each have unique strengths and weaknesses, it seems reasonable that some practice attributes would matter more than others.
Some practices are open late and on weekends, but may not offer flu shots. Other practices may have very long waits for appointments. But they may be built around a provider who is keen to build strong relationships with patients, which takes time. And some practices may deliver mental health services, but choose to refer out for basic dermatologic problems (e.g., wart removal). What matters more?
Back to the foundations of primary care
This study suggests to me that improving primary care may not really be about emphasizing any single attribute. Instead, it may simply require being a well-rounded practice that embraces the core elements of primary care: accessibility, continuity (or longitudinally in its original parlance), comprehensiveness and coordination of care. Dr. Barbara Starfield (my own mentor, and the mentor to so many studying primary care) defined these core attributes long ago.
Identifying, describing and measuring the elements of primary care practice certainly helped to distinguish this field of medicine. But those elements are also, in many ways, inseparable. If someone wants a flu shot, they need a practice that both offers it and that is accessible enough for patients to get it quickly. In hindsight, maybe there is some folly (of mine) in having tried to piece apart what matters the most in primary care.
Perhaps there is no true high-value PCMH to streamline. Perhaps it is enough to embrace the PCMH generally. On the other hand, the authors of this study have suggested that the results might look different with a longer study period. They note the near u-turn in trends in ED visits and hospitalizations in the high-value PCMH clinics, even if they were not statistically different from the controls (see the figure). And they are right that the direction of trends in those services suggest something to monitor.
If that turns out to be the case, that will help repair the tiny crack in my faith in primary care.
Gregory Stevens
Dr. Stevens: I generally liked your commentary on the Primary Care Medical Home (PCMH) and its failure to so far deliver on its promise. I would attribute this to a misunderstanding of what PC can deliver, and at what cost (because, of course, there is a cost). Often stated in terms of the “Triple Aim”: Increased quality, greater patient satisfaction, and lower cost (sometime increased to the “Quadruple Aim” to include clinician satisfaction and lower burnout), the concept was bought into by many of the powerful players in the health system (also mostly part of the PCPCP, Patient-Centered Primary Care Collaborative) with focus on the “lower cost” part. To achieve the other 2 (or 3) aims of the PCMH, indeed to deliver on Dr. Starfield’s statement of its advantages, requires investment. It means that clinicians need to be able to spend more time with their patients, be available to them, and churn fewer patients through their day. Some of this can be helped by having other, lower paid, staff, do the tasks that formerly were done by doctors (and NPs and PAs), as you note, but this also requires an upfront investment in hiring and training the staff. Instead, we see too often efforts to develop patient registries, etc., dumped on the clinician by requiring the data to be entered into the right place in the Electronic Health Record, which has increasingly become the bête noir for clinicians who often find the charting-to-patient contact ratio to be or exceed 1:1.
This is not to say that Dr. Starfield is incorrect, or that the Triple (or Quadruple) Aim is impossible to achieve. But the “lower cost” is a long-term result, largely from less need to use expensive specialists, as well as fewer hospitalizations. It requires not only a longer timeline than most corporations (even those ostensibly not-for-profit) are willing to tolerate, but it is the end result, and requires investment up front, while those employers and insurance companies want to take the savings up front, and then can’t understand why quality, patient satisfaction, and clinician satisfaction go down. In addition, much of the failure to decrease expensive outcomes (e.g., hospitalizations) results from the fact that so much of our population is uninsured or poorly insured that they do not seek early care, or can’t get into care, because we have too few PC clinicians because they are overworked and underpaid relative to other specialties.
I have addressed a few of these issues (including the positive joy of primary care) in a recent editorial I wrote for the journal Family Medicine (https://journals.stfm.org/familymedicine/2022/january/editorial-jan22/), and I often discuss aspects of this in my blog, Medicine and Social Justice (https://medicinesocialjustice.blogspot.com) which frequently is also picked up by the MC blog. Maybe I’ll use these comments as the basis for another blog post!
Thank you for raising these issues.
Josh Freeman