Home Is Where the Laboratory Is: The PCMH as a Laboratory for Performance Measure Development

The patient-centered medical home (PCMH) is a rapidly emerging delivery model intended to increase the quality and effectiveness of primary care, increase recruitment and retention of primary care physicians, nurses, and other staff, and make care more affordable. The PCMH may well be the single most important innovation in primary care in recent years.

A surprisingly broad coalition of payers, purchasers, and professional organizations have developed and embraced the PCMH model and PCMH demonstration projects are widespread across the United States (1). In addition to promoting practice-based improvement tools, the PCMH is also a new payment model meant to reduce the perverse incentives of traditional fee-for-service insurance and reward primary care teams for previously unreimbursed services such as coordination and population health management (2). If successful, the PCMH would replace the troubled current model of primary care delivery characterized by fragmentation, fiscal insolvency, and a severe workforce crisis.

Because the PCMH model depends on the successful implementation of a number of care delivery innovations, it is also a natural laboratory for the development of a broad variety of performance measures. To assess the new capabilities of a PCMH, we will need robust measures in areas such as the performance of the team-based care model, improved communication with patients outside of the traditional face-to-face encounter, the effectiveness of patient self-management, and the innovative use of health information technology. Given the range of demands, currently available performance measures are unlikely to be adequate to the task.

A key challenge for PCMH development has been to translate appealing measurement and accountability concepts into practical, useful performance measures. Although the prototype of the PCMH was designed in the 1960's to improve care for chronically ill children, performance measurement and performance-based payment were not central components of the early model. In 2007, the National Committee for Quality Assurance (NCQA) developed a foundational framework for performance measures that could both drive systemic re-design and enable regulators, payers, and patients to assess whether the PCMH is delivering on the promise of higher quality care.

As evaluators of ongoing PCMH demonstration projects and participants in a large evaluator's collaborative sponsored by the Commonwealth Fund, we have identified several measures that can be used to evaluate the success of PCMH implementation (3, 4). Measures used to evaluate the effectiveness of PCMH demonstration projects may not be the types of performance measures needed to support performance-based payment or care improvement. For example, measures of staff satisfaction may be useful to understand the effect of PCMH on staff retention, but this set of measures would be unlikely to be used in a payment model. We believe the insights of evaluators can be useful to developers of regulatory standards and performance measures. We see four key challenges:

Challenge 1: Specifying measures that address the broad scope of activities of the PCMH, but minimize the measurement burden for providers.

Most current measures of health care quality are based on clinical science and clinical guidelines, but the PCMH model includes innovations that are grounded in management sciences, education, psychology, and information sciences. These innovations include team-based care, proactive disease management by non-physician staff, engagement of patients and their caregivers in shared decision making, teaching chronic disease self-management skills, and innovative use of electronic health record systems to improve communication with patients outside of in-person visits. Measuring performance in these areas without disrupting care delivery is a delicate balancing act. For example, significant staff time and resources are required to complete formal practice certification tools such as the initial version of NCQA PCMH medical home standards (1).

To minimize the burden on practices, evaluation teams have used existing Healthcare Effectiveness Data and Information Set (HEDIS) metrics and claims data to assess the effectiveness of the PCMH model. These metrics represent a reasonable starting point, but performance measures needed to assess the innovations noted above may require other types of data collection such as patient experience surveys, surveys of staff experience, functional status assessments, and electronic health record queries. Moreover, the broad menu of practice improvement tools and the variety of local models of implementation across the U.S. further suggest that selecting a priori the best targets for measurement of PCMH performance is no trivial task.

Challenge 2: Establishing a realistic timeline for the introduction of performance measures.

Transformation of primary care practices is proving difficult and time consuming (5). Medical home providers face substantial pressure from payers and funders to demonstrate cost, quality, and patient experience results in the short term. However, measurable changes in clinical process depend on new staffing approaches, changing the allocation of tasks, and deploying new technologies. Improving patient health outcomes depends on the cumulative effect of these changes. Preliminary research suggests that practice transformation may take more than two years to produce the type of practice that can deliver the benefits of enhanced primary care. Measures of patient experience may even deteriorate initially as practices modify their delivery approach (6). Measuring performance under such dynamic and evolving conditions may produce misleading results in the short run, with practices that are doing little transformation scoring better than those that pursue transformation more aggressively.

Challenge 3: Selecting optimal measures of the impact of PCMH on the quality and costs of care.

Demonstrating better health outcomes is a desirable goal of any intervention in health care delivery. However, the diversity of patient conditions, care needs, and services provided by the PCMH makes the selection of specific health outcomes difficult. Among current demonstration projects and their evaluators, there is an emerging consensus that the PCMH model must quickly demonstrate the capacity to slow the growth of costs and achieve greater efficiency of care delivery in order to justify investment of additional resources. Table 1 (below) includes a practical set of metrics that could be used to assess the cost-saving effects of the PCMH (3). Operationalizing these standard measures in current PCMH demonstration projects is an important near-term goal.

Because the quality of care in a PCMH involves a more patient-centered approach, measures of interpersonal quality that assess the effectiveness of patient-provider relationships are needed. The four cornerstones of primary care from the patient's perspective (access, continuity, comprehensiveness, and coordination) offer a framework for measure development. However, to date, medical home demonstration projects have relied for quality measurement on nationally-endorsed claims-based measures of preventive services (such as appropriate vaccination administration or mammography) and chronic disease performance (such as Hemoglobin A1C levels and cholesterol management). Such measures are feasible and offer a basis for performance-based payment, but they are incomplete.

The example of continuity of care measurement is instructive. Patient-provider continuity is associated with a variety of improved outcomes (7), but current claims-based or patient survey tools do not measure continuity well. The newly available medical home-focused version of the Clinician Group Consumer Assessment of Health Plan Surveys (CG-CAHPS) attempts to capture continuity through patient report. However, there are challenges. For example, patients have difficulty identifying the "team" that provides team-based care, finding it easier to report about their "doctor." Moreover, the segmentation of care tasks within a team (i.e., several providers each carrying out tasks according to their professional competencies) could seem fragmented to patients if the team members do not coordinate their activities effectively, or have the electronic tools to do so. The development of new measures of continuity that can be used in small practice settings should be a priority. For instance, continuity measures based on claims data may have limited use in a PCMH where the activities of team members and care delivered between visits will not generate claims.

Evaluations of the PCMH have tended to emphasize qualitative methods such as case studies, interviews, and human factors analysis from business and management science. While these methods are not suitable for routine performance measurement, their use in the National Demonstration Project has created a new, useful measurement vocabulary including a survey instrument that can be used to assess the readiness of a practice to change (5, 6).

Challenge 4: Feasibility of performance measurement in the PCMH.

The PCMH will confront a variety of logistical barriers to performance measurement. Many medical home practices are small, yielding small sample sizes for the measurement of the quality of care for conditions like congestive heart failure (CHF). Furthermore, comparing performance of medical homes will be challenged if it is necessary to account statistically for the clustering of patients by provider or practice. Surveys of staff and patients can be time consuming. Development of interoperable electronic health records and registries that enable the passive collection of performance data using routine clinical data will be critical for enabling real-time performance measurement. Alignment of federal "meaningful use" criteria for health information technology with NCQA medical home standards is a welcome development. At present, most electronic health records fail to offer necessary functionalities. They will need to be improved if the PCMH model is to flourish (8).

Conclusion

The PCMH provides a template for a fundamental restructuring of primary care delivery in the U.S., and there are strong hopes that it will help improve care and slow cost growth. But as payment reform demands effective performance measurement, the PCMH model must have effective performance measures. Otherwise, the PCMH is unlikely to play a prominent role in health system transformation. PCMH demonstration project evaluators are building a knowledge base for innovative performance measurement strategies even though the first projects have used existing performance measures that are feasible to implement. Indeed, lessons from the current PCMH demonstrations will certainly inform performance measure development for other payment reform models (such as global payment and bundled payments) and for nascent entities like accountable care organizations.

Table 1: Recommended Cost and Efficiency Measures*

*Source: Rosenthal MB, Beckman HB, Dauser Forrest D, Huang ES, Landon BE, Lewis S. Will the patient-centered medical home improve efficiency and reduce costs of care? A measurement and research agenda. Med Care Res Rev 2010 Aug; 67(4):476-84.

Authors

Asaf Bitton, MD, MPH, FACP
Division of General Medicine, Brigham and Women's Hospital
Department of Health Care Policy, Harvard Medical School, Boston, MA

Eric C. Schneider, MD, MSc, FACP
Division of General Medicine, Brigham and Women's Hospital
RAND Boston, Boston, MA

Disclaimer

The views and opinions expressed are those of the authors and do not necessarily state or reflect those of the National Quality Measures Clearinghouse^™ (NQMC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor, ECRI Institute.

Potential Conflicts of Interest

Dr. Bitton disclosed he has received research funding from the Commonwealth Fund to study PCMH and, in August 2011, he will be the Assistant Medical Director of a new PCMH clinic in Boston, MA.

Dr. Schneider notes that he is a member of the NQMC/NGC Core Editorial Board and Chairman of the Panel of Experts for NQMC and NGC, and is receiving grant support from the Commonwealth Fund and Robert Wood Johnson Foundation to evaluate PCMH demonstration projects.

References

1. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med 2010 Jun; 25(6):584-92.
2. Schneider E, Hussey PS, Schnyer C. Payment Reform: Analysis of Models and Performance Measurement Implications. Santa Monica, CA: RAND Corporation, 2011. http://www.rand.org/pubs/technical_reports/TR841 .
3. Rosenthal MB, Beckman HB, Dauser Forrest D, Huang ES, Landon BE, Lewis S. Will the patient-centered medical home improve efficiency and reduce costs of care? A measurement and research agenda. Med Care Res Rev 2010 Aug; 67(4):476-84.
4. The Patient-Centered Medical Home Evaluators' Collaborative, The Commonwealth Fund, March 2011. http://www.commonwealthfund.org/Content/Publications/Other/2010/PCMH-Evaluators-Collaborative.aspx . (Accessed May 31, 2011).
5. Nutting PA, Miller WL, Crabtree BF, Jaen 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 7(3): 254-60.
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