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A skeptical look at primary care in the medical home

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Robert Berenson and Rachel Burton look at the solidity or lack thereof of the primary-care foundation of the patient-centered medical home (PCMH)

They write  in HealthAffairs “{A} recent summary of the latest evidence found reason for optimism about the potential impact of the PCMH model, not only on quality but also physician morale — raising the hope that the proliferation of the PCMH model might attract more physicians to careers in primary care.

“At the same time, more robust studies that have used difference-in-differences analyses—controlling for the likelihood that practices that become PCMHs might be higher performers to start with—had less impressive results, especially regarding healthcare spending….”

“But there’s a more fundamental issue to consider regarding which aspects of primary care practice make the difference in performance. Many of the versions of the PCMH—and the accompanying recognition instruments that assess practice adoption of the PCMH model—do not assure that the well-established four ‘pillars’ of primary care are robustly adopted by PCMH practices. Rather, it’s simply assumed, despite growing evidence to the contrary, that practices are meeting the ‘four C’s,’….— providing first contact, continuity, comprehensiveness, and coordination.

“We would suggest the current emphasis of PCMH demonstrations and models on the fourth C, care coordination, is partly a reaction to decline in primary-care commitments to the three other C’s,contact, continuity, and comprehensiveness — decline that seems to have been simply accepted as facts of life by most PCMH architects. It’s no wonder the PCMH emphasizes care coordination — much of the care received by primary care clinicians’ patients is now being performed by others, without their involvement.”

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