- Primary care providers may not be providing all the benefits the patient-centered medical home (PCMH) has to offer, according to a study in the American Journal of Managed Care, lagging behind their specialist peers in several measures of satisfaction and care delivery.
While the parents of pediatric patients are generally happy with the quality of care they receive from both specialists and PCPs, primary care providers operating under the PCMH framework could do a better job with the outreach and education portions of the coordinated care model.
“Little is known about parents’ perceptions of medical home elements in specialty care or how they compare with those of primary care practices,” said researchers from the University of North Carolina and Duke University.
“Such knowledge might allow practices to provide more patient-centered care and tailor future efforts to improve care coordination.”
The team fielded a patient satisfaction questionnaire to 685 parents and caregivers of children with chronic illnesses who required both specialty and primary care.
The surveys, available in both English and Spanish, asked parents to assess how often their children were offered services that align with the principles of the patient-centered medical home, including extended hours and same-day appointments, tailored patient education, care coordination, and online access to data.
Both primary care providers and specialists received high marks for care coordination, with 88 percent of respondents indicating satisfaction, and saw similar levels of success following up on referrals.
Primary care providers offered better appointment availability – 93 percent approved of how their PCPs handled scheduling appointments versus just 87 percent for specialists – but in all other PCMH arenas, specialists beat out their PCP peers.
Specialists were more adept at meeting PCMH criteria including electronic prescribing (90 percent versus 86 percent), sharing test results (80 percent compared to 75 percent), distributing handouts (77 percent versus 70 percent) and delivering reminders.
Ninety-nine percent of respondents said that their specialists provide appointment reminders, compared to just 89 percent of PCPs. Specialists were also 11 percent more likely to deliver reminders for tests that were due.
Forty-three percent of parents said their specialists offer email capabilities, but just 28 percent of PCPs did the same, the survey found.
“For parents of children receiving care in both primary and specialty practices, these findings raise important questions about their interaction with a primary care-based medical home,” the authors said.
The study isn’t the first to highlight significant variability in how providers apply the principles of the PCMH to patient care.
While this survey found high levels of satisfaction with how primary care providers handle care coordination and the referral process, a separate study from December 2016 indicated that primary care providers with less experience are much more likely to refer adult patients to specialty providers than PCPs with more time on the job. Multiple referrals may be necessary for patients with complex needs, including children with chronic diseases, but too many specialists involved in a single patient’s care may contribute to data fragmentation, service duplication, and unnecessary expenses.
Other research has focused on the high costs of implementing and maintaining the PCMH. In 2016, RAND Corporation pinned the cost of PCMH upkeep at $147,000 per year, while a 2015 study from the Annals of Family Medicine asserted that the staffing and care coordination requirements included in the model can sap more than $100,000 per full-time clinician from an organization annually.
Whether these high costs are worth it is also up for debate. There is plentiful evidence both for and against the effectiveness of the model, with some organizations seeing lower costs, better quality, and higher rates of patient satisfaction, and others sinking under the administrative and technological burdens of implementation and maintenance.
Pediatric care adds a second dimension to the problem of ensuring that patients receive maximum benefit from the framework. Many of the PCMH requirements focus on tailored care planning, individualized education, and cooperative decision-making, but minors often rely on their parents to engage with the healthcare system on their behalf.
A parent’s perception of care may differ significantly from their child’s satisfaction with their providers, and differing levels of comfort with navigating the care system, working with clinicians, and maintaining familiarity with online communication options could impact the results.
The study did not address any potential differences in opinions between parents and their children. The researchers also note that the data was collected in 2012, before the healthcare system had invested heavily in digital care coordination and patient engagement tools.
Nevertheless, the study highlights a significant discussion point for patient-centered medical home advocates and detractors alike.
“Given the importance of the medical home in children with chronic illnesses, this study provides important insight into how parents view and compare medical home aspects of different care settings,” the authors said. “This information is valuable to primary and specialty physicians caring for such populations, enabling them to better work together and with families to strengthen medical homes.”