Why was the Patient Centered Primary Care Medical Home unsuccessful? It was not really implemented!

 

In a recent post on the blog of the Medical Care section of the American Public Health Association (APHA), Dr. Gregory Stevens wrote Is something going wrong with the Patient-Centered Medical Home? His concern was engendered by the results of a study in the journal Medical Care (also published by the Medical Care section) by Colasurdo, Pizzimenti, et al., “The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results”. This study examined a sample of practices implementing the PCMH model and showed varied results. The trends were toward more emergency visits, fewer hospitalizations, and unchanged costs. This was not supposed to be the result, and was a disappointment to Dr. Stevens, especially given that he was mentored by Dr. Barbara Starfield, whose research documented the beneficial impact of Primary Care on quality of care, cost, and population health.

First, some effort to clarify the terms; PCMH stands for both Primary Care Medical Home (as it generally does in the settings studied by Colasurdo, et al.), as well as Patient-Centered Medical Home, which is the term Dr. Stevens uses (actually, Colasurdo. uses both. The fact that both Primary Care and Patient Centered have the same initials is kind of cool, but it can be confusing, Indeed, in 2006 an organization called the Patient-Centered Primary Care Collaborative (PCPCC) was created. The impetus came from Dr. Paul Grundy, a physician and former VP of IBM who had recognized that the medical care costs paid by IBM in countries with a strong primary care base were much lower, even when controlling for the fact that many of those countries had national health insurance (because, in either case, IBM was paying the costs). This group, now renamed the Primary Care Collaborative, counts as members providers (both physicians and health systems), insurers, employers, pharmaceutical companies, patient-advocacy groups, and others. At the time of its creation, it was considered potentially revolutionary; with all of these major groups ostensibly buying into the benefits of primary care, the primary care specialties (family medicine, general internal medicine, general pediatrics) thought that there might finally be adequate recognition of their work. So, while of course being “Patient-Centered” is very important, it is the “Primary Care” that characterized these practice changes.

They were optimistic, but, unsurprisingly, overly optimistic. While having all those players in the PCPCC seemed like a good idea, but their agendas are not necessarily aligned with those of primary care; they can be summarized as “make money”. So they loved the “at lower cost” piece, and kind of liked the idea that maybe there was something magic in primary care that could lead to higher quality and greater patient satisfaction while spending less. Of course, it is not magic, but requires a coherent strategy to implement a structure in which the strengths of primary care were realized.

Dr. Starfield identified these strengths as the “4 Cs” of primary care:

• first-Contact care

• longitudinal Continuity over time

• Comprehensiveness, with capacity to manage majority of health

problems, and

• Coordination of care with other parts of the health care system

Starfield states ‘A primary care physician practices first-contact, comprehensive and coordinated care within the context of long-term person-focused relationships.’ (Starfield B, Oliver T. Primary care in the United States and its precarious future. Health & social care in the community. 1999;7(5):315-323). These characteristics allow the identification of which specialties are actually primary care (family medicine, general internal medicine, general pediatrics, geriatrics) and which are not. For example, it does not include either emergency medicine (yes for first-contact, no for continuity) or obstetrics-gynecology (many women’s primary physician, but scarcely comprehensive, dealing only with the reproductive tract).

The term PCMH (whichever “PC” you choose, or both) has not much been used lately. The more recent formulation has been the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost, even more recently expanded to include physician (or clinician) satisfaction and lower rates of burnout to make it the “Quadruple Aim”. But, according to the study by Colarsudo and summarized by Stevens, it hasn’t worked. Why?

There were two major flaws in the implementation of the PCMH (or, if you like, PCPCMH). The first is a national issue which needs to be addressed as a baseline, something which is necessary if not sufficient to ensure quality, is that the US does not have a universal health insurance system. (And, of course, everyone is not covered by IBM.) That means that whatever the benefits of primary care are (and I believe they are enormous), they will not be realized by the entire population, The fact that so many people have no insurance or have inadequate insurance makes the whole enterprise of trying to reform the American health system in any significant way impossible. When so many people haven’t got the money to access medical care (and in this regard, having poor quality insurance, with high copays and deductibles, is often worse than no insurance, despite what advocates for ACA / Obamacare claimed), they delay care. They not only end up in the emergency room rather than a primary care office, they end up there when they are much sicker, more likely to require hospitalization, and more difficult to treat and cure. Until this is addressed, any attempt to make any kind of major reform that is intended to improve the health of the overall population is doomed.

 

The other major flaw in implementing the PCMH was that the power players in US healthcare, the health systems and insurance companies, decided to try to realize the lower cost on the front end. They did not make the investments needed to ensure that primary care could function effectively to achieve what should be considered the two truly important aims, higher quality and greater patient satisfaction. As in every endeavor that seeks to make – or save – money, course upfront investment was necessary, but shockingly little was invested. For starters, there was a need for a lot more primary care clinicians than we currently have in the US to be able to ensure that people can have access, and that doctors have enough time with their patients and are not being asked to churn so many patients through. Without this you won’t be able to realize the long-term benefits of primary care identified by Dr. Starfield and others. You won’t get quality or patient satisfaction if people are being rushed through like cattle.

For there to be enough primary care physicians and other clinicians you have to start with paying them more without concomitantly asking them to “produce” more. Too few medical students are entering primary care, seeing both the heavy workload and relatively lower pay (also a marker of lower status). Concomitantly, to the degree that achieving these goals can be facilitated by other staff doing much of the work to maintain registries, remind patients of preventive care, etc., those staff have to be hired and trained. The wrong way to do it is how it has been done: requiring the clinician, rather than other staff, to enter all this data into the Electronic Health Record, using the most expensive and highly-trained members of the team to spend their time doing secretarial work instead of seeing patients. Indeed, primary care clinicians are now finding that they often spend more time charting than interacting with patients; this is a recipe for them to burn out and leave, not to increase either their satisfaction or that of their patients.

The solutions are clear – take care of the problems. More students need to choose to enter primary care, and this means that primary care clinicians have to be paid as much as other specialists (whether by paying PC more or paying the others less) and have workloads that encourage them to spend as much time as necessary with each patient listen to them, address their problems, and communicate effectively; that is, to provide them with quality care, to be able to deliver on the potential benefits of primary care. The cost savings come at the back end, from fewer unnecessary referrals to other specialists, from fewer emergency visits, and fewer hospitalizations. But they come after the necessary investments have been made and the systems have time to adjust. As in any other industry you cannot take your profit before you have produced your product.

And, of course, we need to ensure that everyone is insured, and well-insured. The best way to do this is to have everyone in the same insurance program, with the same benefits. Medicare for All. Everybody in, nobody out.

“You’re On Your Own”: How the U.S. response to COVID revealed the flaws in the public health system

 This piece is a guest essay/book review by Ken Rosenberg, MD 

 

“The Premonition: A Pandemic Story” is Michael Lewis’ love letter to local health officers who are trying to do an impossible job. It is also a compelling analysis of why the U.S. public health system is not capable of effectively responding to a rapidly moving pandemic.

In 2018, Michael Lewis published “The Fifth Risk” in which he described the Obama administrative staff preparing detailed briefings for the incoming Trump administrators and finding that no one from the incoming Trump administration showed up to get briefed. When COVID quickly got out of hand, Lewis assumed that Trump and his fellow anti-government conservatives were at fault. But once Lewis started looking into the U.S. government’s COVID response he discovered a set of problems that was more complex and much more disturbing. 

Dr. Charity Dean, the Santa Barbara (CA) County health officer, was passionate in trying to prevent communicable diseases. She had sought help from the Centers for Disease Control and Prevention (CDC) in controlling outbreaks of tuberculosis, hepatitis, meningococcal disease and H1N1 influenza before COVID. She had found that CDC was risk-averse: they would not recommend a course of action. They hid behind the argument that nothing should be done unless there was sufficient data to support a decision. “She never had all the data she wanted or needed when making her decisions…People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission get you fired. Sins of omission you could get away with, but they left people dead.” CDC’s mantra was “That decision is not supported by the data.” But Charity Dean knew that there was no data. Her mantra became “You’re On Your Own.”

 

[cartoon Hillary Fitzgerald Campbell, the New Yorker]

Similarly, everywhere he looked, Michael Lewis found a dysfunctional public health system where local public health officers were on their own with little support from the federal government. CDC, once run by infectious disease experts, had become a risk-averse academic bureaucracy run by political appointees. Their expertise had become the study of past events more than advice to health departments on what they should do in a crisis. And government agencies outside CDC, like FEMA, refused to take leadership in pandemic planning. In the end, a few individuals, both inside and outside the federal government, did what they could to craft a pandemic response -- without telling their bosses.

The U.S. public health system is relatively good at handling the prevention of chronic diseases – when it is adequately funded. (It is mostly not adequately funded.) But Michael Lewis found that it was not good at providing support for local health departments in how to handle epidemics. Bureaucracies do not do well working across silos. CDC is not structured to take leadership in a fast-moving prevention situation and its funding for emergency preparedness shrank by about half in the past ten years.(1)

“The Premonition” has two significant weaknesses:

(1) Although “The Premonition” purports to be a critique of the U.S. public health system, it is mostly about our inability to handle epidemics, especially fast-moving epidemics.

(2) “The Premonition” does not explore why there is a gap between the needs of local health officers and the federal public health agencies that are supposed to be supporting them. Much of the gap is due to changes in the field of epidemiology in the past 40 years. With the development of commercial data analysis software, epidemiology has largely changed from the practical work of public health to the analysis of risk factors. Academic public health currently spends much of its energy promoting evidence-based public health decision-making although local public health practitioners spend most of their time making decisions without the benefit of sufficient evidence. Currently both academics and CDC focus on promoting evidence-based decision-making while denigrating decisions that are not supported by evidence-based epidemiologic methods. By focusing primarily on evidence-based science, CDC has failed to explore and promote information that would help local health departments do their job in the absence of adequate information.

There are three main lessons of “The Premonition.” The first is that the U.S. public health system needs to be restructured so that 1500 local health officers are not forced to reach their own conclusions (often based on insufficient evidence) on how to save lives in an epidemic. Federal (and state) governments need to find a way to support the work of local health departments in epidemic times.

The second lesson is that public health needs increased stable funding. We continue to fund public health “in response to particular threats and then let our interest lapse when the immediate crisis seems to be over….[W]e should not allow ideological shifts and inevitable economic cycles to deflect us from maintaining appropriate public and governmental responsibility for the health of the community.”(2)

The third, and perhaps the most important lesson, is that public health must return to its origins in advocacy to eliminate social inequalities and what we now call the “social determinants of health.”(3) In the late nineteenth and early twentieth centuries, American public health’s mission was social reform, identifying itself with housing, sanitation, and labor reform efforts. “[P]ublic health professionals have, over the course of a century, defined their mandate ever more narrowly….For many decades, the field has…avoided engagement with those who challenge complacency and existing power relationships….Forsaking its early ideology, commitments, and crusading spirit, public health became unwilling or uncertain about how to use science to challenge powerful corporate interests, deeply entrenched moral beliefs, or profound social inequalities linked to gender, race, and class.”(4)

Public health needs to return to its advocacy roots – by reconnecting with labor, housing, transportation and other insurgents – “to deal with the problems that truly define the public’s health.”(5)

FOOTNOTES:

1. Trust for America’s Health. The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2021. At: https://www.tfah.org/report-details/pandemic-proved-underinvesting-in-public-health-lives-livelihoods-risk/

2. Elizabeth Fee, Theodore M Brown. The unfulfilled promise of public health: déjà vu all over again. Health Aff (Millwood). Nov-Dec 2002;21(6):31-43

3. https://en.wikipedia.org/wiki/Social_determinants_of_health

4. Amy L. Fairchild, David Rosner, James Colgrove, Ronald Bayer, and Linda P. Fried. American Journal of Public Health. January 2010, Vol 100, No. 154, pages 54-63

5. Ed Yong, “How Public Health Took Part in Its Own Downfall,” The Atlantic – Oct 23, 2021. At:  

https://www.theatlantic.com/health/archive/2021/10/how-public-health-took-part-its-own-downfall/620457/

 

Kenneth D. Rosenberg, MD, MPH, is a public health epidemiologist. He worked for many years for the New York City Department of Health and the Oregon Public Health Division.

 

Thanks to Kendall Belmont and Patrick Lemmon for their editorial assistance.

 

It's not just about the emergency. It's about restructuring society so we have the ability to deal with crises.

A recent article by Jennifer Sinco Kelleher and Terry Tang from the Associated Press, highlighted in Medscape, is called “Omicron Explosion Spurs Nationwide Breakdown of Services”, and is one of many pieces documenting how this extremely contagious (if possibly more mild) variant of COVID-19 is continuing to overwhelm not only healthcare, but almost all areas of our society:

Ambulances in Kansas speed toward hospitals then suddenly change direction because hospitals are full. Employee shortages in New York City cause delays in trash and subway services and diminish the ranks of firefighters and emergency workers. Airport officials shut down security checkpoints at the biggest terminal in Phoenix and schools across the nation struggle to find teachers for their classrooms.

It goes on. One of the major flashpoints has been whether schools should reopen, often ostensibly pitting parents (who not only are feeling overwhelmed with having to supervise their children’s online education, but often have to go back to work themselves and have no one to watch their kids) against teachers (who are reasonably terrified of contracting COVID infection – and transmitting it to their own families). Of course this is overly simplistic; parents want their children to be safe and remain non-infected, and teachers want children to be educated – often this is not only their job but their calling! Michelle Goldberg in the New York Times argues that American Federation of Teachers (AFT) President ‘Randi Weingarten Still Wants Schools Open’, as she wrote a month ago. But there are many who are determined to pander to their political bases (like Oklahoma senator Tom Cotton, whom she cites) by creating bogeymen to attack.

But it has been, in case you haven’t noticed, a very stressful two years. The schools may affect a huge number of people, but so does healthcare. Kelleher and Tang emphasize the impact on healthcare, including my old hospital, the University of Kansas in Kansas City, where

The number of COVID-19 patients at the University of Kansas Hospital rose from 40 on Dec. 1 to 139 on Friday. At the same time, more than 900 employees have been sickened with COVID-19 or are awaiting test results — 7% of the hospital's 13,500-person workforce.

Paramedics are working 80 hours a week. There are simply not enough skilled people to do the work. And it is getting worse as more and more of them get sick. The always-overtaxed staff in our healthcare facilities has become more and more overtaxed by the increase in demand and the decreased number of workers. ‘"Everybody's working 'round the clock, 12-hour shifts” says New York City’s sanitation commissioner, and it is true in many fields.

It is tempting to say that this is, in large part, a result of “chickens coming home to roost”, of two generations of cutbacks in staffing and “just in time” supplying, of corporate consolidation and downsizing and increasing profits to please investors by overworking those who are left, of rewarding this with huge salaries to the C-suite executives. Well, it is, largely. We have been though a long period of rapacious exploitation of the workforce, and it is a big part of why there was nowhere near enough “flex” in the system to accommodate the huge demands of the COVID pandemic.

The news has also featured stories about the increasing power of workers, given the current labor shortages, and a few recent strikes that have been won. This is good, but it is not enough. Many hospitals have lost staff; nurses have not only stopped coming to work but have even left the profession. Not all of them would still be there if they were being paid higher wages, but it would help. It has been interesting to see that hospitals are willing to pay agencies huge amounts of money -- $100-200 or more an hour – to get “travel nurses” (nurses who will travel from where they live to your town for the more money) but not to significantly increase salaries for full-time nurses. This is part of an overall approach that sees the pandemic as a temporary blip – we can pay these high daily rates for a while, but really do not want to increase actual salaries in the long term. Reward those doing the work? Isn’t that communism?

Indeed, this is kind of the approach that the government has been taking overall; Trump or Biden, Republican or Democrat, trying to say “this will soon pass”, we can get back to normal, we can “open up”. It pleases folks who are frustrated at being at home and being on Zoom and not eating out or clubbing or whatever to hear that. Until they get sick. It must please some of the members of the Tucson Racquet and Fitness Club, who despite a county indoor mask mandate and a request from the management continue to wear masks indoors, do not -- like the two young women who held a 45-minute maskless conversation 10 feet from my machine today. Until they get sick. Probably not until they make someone else sick, since they won’t know. The county is not enforcing the mandate and the Club and stores are afraid to; supermarket managers talk of verbal and physical assaults on their employees. The stock market really likes the idea that things will get back to normal, since “normal” has been a rising market; plus all the richest investors make money either way.

Of course, people with some jobs have been hit harder than others. Those who must be physically present at work have been unable to “phone (or Zoom) it in”. And healthcare workers, doctors, nurses, and others, have been exploited by a culture which knows that they will sacrifice much for the welfare of their patients, and is willing to push it to the max. Or more. This is not ok. There is no reason for any healthcare system to be making money (whether it is called “profit” or something else in not-for-profits) or paying its executives huge salaries while the staff is getting sick, doing double shifts, burning out. It is not just about paying people more (although often this is important); it is about a paradigm shift that recognizes that long-term commitment to those doing the work needs to be the priority. It is about having enough workforce to be able to cope with increased demand when it happens.

Reminder #1: The entire structure is geared to the goal of increasing the wealth of those who already have the most and have the most power.

Reminder #2: This is not how it should be.