I plan to work on NCQA certification for a patient centered medical home very slowly.
I fear that by just saying “bah humbug” immediately gets me dismissed as someone not interested in moving family medicine forward, but if I were able to qualify as a Level 3 PCMH (and I think I can), then hopefully I can work from within the system to tell people the certification is ridiculous and will not result in a better or more efficient system. Why?:
1) A huge portion of the PCMH is database stuff—Do you have the EMR necessary to collect the data? Do you have protocols for how to handle the collected data? Do you have authorized personnel who can then translate the data to the patient and to the government?
My tangential question is “how many docs enjoy doing billing?” The answer is, of course, none. Why? It is a mind numbing, frustrating, infuriating process of data processing. So, how many docs will do their own data collecting? Well, none. So are we just creating an entirely new field of “chronic disease analyst” so we can then pay someone else the extra income we are making (if we make any) so the appropriate boxes will be checked? Well, yes. So how does having more people between the doctor and the patient strengthen the doctor-patient relationship and how does that impact a med student’s decision to choose family medicine as a career?
2) The PCMH criteria are skewed toward large practices—I have to write up protocols stating that I have written guidelines on how to treat diseases so all the providers (which would be me) follow the same guidelines. Umm, I hope that I am relatively consistent with how I treat my diabetics, but the protocols must be written anyway.
3) There is little evidence which shows incentive payments for data analysis actually improves outcomes. This is a little scary to talk about, but there was a study (Coleman et al., “The Impact of Pay for Performance on Diabetes Care in a Large Network of Community Health Centers”) which showed that P4P initiatives lead to increased testing, but that there was little impact on the results. In fact, overall HgbA1C went up showing that getting the data does not necessarily mean that data will impact the patient’s life resulting in better outcomes. Think about this for a moment. The entire argument for the patient centered medical home is that it will save money through providing superior care, but there is paltry evidence (that I have seen) which shows giving docs incentives to meet a laundry list of guidelines works. This is no surprise because data collection is not as important as a good relationship in instigating change.
4) Does going through the process actually make a practice better? Not likely. Practices which are doing a good job will likely get certified but the process will not make them better. Poorly performing practices cannot get certified so they won’t try. Others will do what they need to do to get certified but will not change the way they practice. This is because changing behavior, even if it is dysfunctional, is very difficult (ask anyone on a diet).
I always go back to the most important question in such passionate discussions. Does what I am doing improve my relationship with my patient? Having looked through the certification process a fair amount, I do not believe getting certified will. And, if it does not improve that relationship, then it will not succeed in improving quality or stopping the failure of primary care to recruit new docs into the ranks. Unfortunately, my fear is that it is a potentially dangerous distraction at a critical time in our specialty--which is why we need to speak up now.
John Brady MD
Newport News VA