Conclusions in PCMH Research Study Drawing Criticism From Family Medicine Leaders

A new study in the Annals of Family Medicine that examines health care quality and patient satisfaction in patient-centered medical homes, or PCMHs, in Minnesota is drawing some disagreement with the research methods and the study's conclusions, including from the AAFP and its wholly owned practice redesign subsidiary TransforMED.

"Trends in Quality During Medical Home Transformation" (7-page PDF; About PDFs) appears in the November/December issue of Annals of Family Medicine. The article, which was published online on Nov. 14, looks at 21 Minnesota primary care clinics that achieved National Committee for Quality Assurance level III PCMH recognition. These clinics have been tracking quality and patient satisfaction measures for a number of years; the study authors analyzed this data and compared the results to other medical groups in the area to estimate expectations for primary care practices to achieve medical home status.

"Our study is important in that it describes the trajectory over time with which clinics that have achieved level III PCMH recognition have been able to improve their patient satisfaction and quality scores as they transformed," wrote the authors.

"As we move rapidly as a nation to encourage transformation of traditional primary care practices into patient-centered medical homes, this study adds to the reasons for avoiding unrealistic expectations about the rate of improvement in health or patient experience that will result," concluded lead author Leif Solberg, M.D., and his coauthors.

"I disagree with Dr. Solberg's final assertion that 'expectations for large and rapid change are probably unrealistic,'" wrote AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, in response to the article.

Goertz pointed to numerous PCMH success stories as outlined in a recent review of evidence (16-page PDF; About PDFs) released by the Patient-Centered Primary Care Collaborative that includes Blue Cross Blue Shield of North Dakota's statewide PCMH initiative. That program showed great improvements in clinical outcomes and process measures during a three-year period, noted Goertz.

Furthermore, he said, the Minnesota practices studied by the authors were located in an "atypically advanced health care market" and the PCMH practices were 10 years into practice improvements that had helped them earn their PCMH recognition.

"The hardest work had been done before the study began," said Goertz, adding that practices and clinics in the study group and the control group were high performers from the outset. "What type of difference in transformational success did Solberg expect to see? What was he trying to prove by comparing such similar, high-performing practices," wrote Goertz.

The 21 PCMH primary care clinics in the Minnesota study were all associated with HealthPartners Medical Group, or HPMG, and were in the Minneapolis metropolitan area. Study researchers examined quality and patient satisfaction measures that had been independently tracked for a number of years by these clinics.

Researchers then compared that data with similar data collected from a second group of primary care medical groups in the same Minnesota community that had not received PCMH recognition but that were moving in that direction with their practice improvements.

The study, which was funded by the Agency for Healthcare Research and Quality, found that rates of improvement in patient satisfaction among the HPMG medical home clinics as a whole averaged only about 1 percent per year for measures having high rates at baseline. And they averaged about 3 percent per year for measures with lower baseline rates. In the quality area, the authors reported increases of 2 percent to 7 percent per year for measures such as for diabetes, coronary artery disease, preventive services and generic medication use.

"The rate of increase (in patient satisfaction rates) among HPMG medical home patients was greater than for patients cared for in other groups, but it only caught up to the community average," said the study authors.

They added, however, that average rates for most performances measures in Minnesota are higher than those in most areas of the country. "There is also an unusually strong cultural tradition in Minnesota of public reporting and sharing of successful improvement strategies that may contribute to the improving secular trends across all groups," wrote the authors. Competing groups in Minnesota share quality results and strategies through the Institute for Clinical Systems Improvement -- a regional quality improvement collaborative.

The authors concluded that although the group of 21 PCMH clinics saw improvements in quality and patient satisfaction during the time frame studied, the rate of improvement was slow and did not always exceed improvement levels in the other non-PCMH clinics studied.

"Overall, the rate of improvement per year is probably not what national policymakers are hoping to see from transformation to medical homes," said the researchers.

Others, however, expressed skepticism about the study. For example, although Terry McGeeney, M.D., M.B.A., president and CEO of TransforMED, applauded the study authors' efforts to assess the effect of the medical home model in a high-functioning multi-specialty group, he noted that an accurate evaluation could only be made after defining and identifying "true PCMH practices."

"One key learning over time is that all of the attributes of the PCMH model of care are interdependent," wrote McGeeney. "There is no data to support that leveraging just some of the attributes of the PCMH leads to incremental improvement in efficiency or quality. In fact, the full value of the PCMH model may not be recognized until a practice is a complete PCMH, which current recognition tools cannot assess or validate."

IBM Global Director of Healthcare Transformation Paul Grundy, M.D., M.P.H., also expressed serious reservations about the study.

"I am sure Solberg's assertion that 'expectations for large and rapid change are probably unrealistic' will probably be used against me as I continue my quest to purchase PCMH-level care for my employees and their families," wrote Grundy.

"I suspect, but hope I am wrong, that this article will do more harm than good toward getting primary care away from buying episodic, uncoordinated, inaccessible and dis-integrated care," he said.

Solberg, the study's lead author and associate medical director for care improvement at the HealthPartners Research Foundation responded by telling AAFP News Now, "It is a little discouraging to have leaders respond to a scientific study that doesn't completely fit their view of what will help them to sell an idea."

In comments on the article itself, Solberg went on to say, "I am one of the greatest boosters of the kind of changes represented by the PCMH. I just think underpromising and overdelivering is a better strategy in the long run than the opposite -- the quickest route to damaging PCMH sustainability is to create lofty expectations that can't be achieved."