An assessment of patient-based and practice infrastructure-based measures of the patient-centered medical home: do we need to ask the patient?

Nearly 10 years ago the Institute of Medicine (IOM) released its seminal report on the state of the quality of health care in the United States entitled Crossing the Quality Chasm (IOM 2001). In addition to providing ample evidence about the deficiencies of the quality of care, the IOM laid out six aims for improving quality; medical care should be effective, efficient, equitable, timely, safe, and patient centered. Progress in improving the quality of health care since the release of this report has been slow, and one hypothesis for the lack of more substantial progress is the eroding state of primary care in the United States. Multiple lines of evidence include the increased administrative hassles faced in a primary care practice, poor reimbursement, loss of physicians from primary care, and declining interest among medical students (Lipner et al. 2006; American College of Physicians 2008; Hauer et al. 2008). However, others also point to the failure of primary care to adopt new approaches to care delivery, quality improvement, and systems science (Baron and Cassel 2008). These concerns led to the creation of, and subsequently intense interest in, a new model of primary care called the patient-centered medical home (PCMH) that is now the subject of multiple demonstration projects across the United States (American College of Physicians 2007; Landon et al. 2010). Principles for the PCMH were developed collaboratively and released by four primary care–related societies in 2007 (American College of Physicians 2007). This PCMH group then worked with the National Committee for Quality Assurance (NCQA) to revise NCQA's existing Physician Practice Connections (PPC) program to create a process for “qualifying” practices as a PCMH at one of three levels (American College of Physicians 2007). NCQA's current tool, the Provider Practice Connections – Patient Centered Medical Home (PPC-PCMH), is being used to “qualify” medical homes for many of these pilots and is almost exclusively focused on the primary care practice's infrastructure (NCQA 2010b). This tool has become the “industry standard” operational definition of the PCMH and is being used by Medicare and private sector payers to qualify physician practices as a medical home (Abrams 2008 Mathematica 2008; Bitton et al. 2010). Recent policy discussion has emphasized adoption of key practice infrastructure capabilities to improve patient care by promoting care management and coordination, and establishing processes to improve access to care and communication (Berenson et al. 2008; Friedberg et al. 2009). Advocacy for the PCMH has formalized assumptions about the link between these infrastructure capabilities and patient-centered care, offering enhanced reimbursement for practices that provide evidence of having such capabilities. However, two recent studies have raised questions about the association between presence of system infrastructure components and quality of care (Friedberg et al. 2009; Holmboe et al. 2010a). In the end, the ultimate success of the PCMH will depend on whether patients’ health care needs are being met. A substantial shortcoming to the current approach to “qualifying” PCMHs is the lack of assessment of patient experience with the practice. One might reasonably ask, “how can we provide patient-centered care if we do not ask the patient about their experience of care?” Yet the 2008 revisions to the PPC-PCMH criteria included only a modest component for patient assessment of the practice (NCQA 2008), despite substantial progress in developing instruments to assess patients’ experiences with their care, such as the Consumer Assessment of Health Plans and Systems (CAHPS) surveys (Safran et al. 1998; Hays et al. 1999). Recognizing the importance of this, NCQA is currently proposing an optional patient experience module to the PCMH process (NCQA 2010a). With this in mind, we examined four hypotheses central to the debate around the importance of the patient's voice when evaluating PCMH qualification. First, NCQA's PCMH infrastructure measure was not strongly associated with patient rating of physician quality. Second, patient-centered care measures from the CAHPS patient survey were strongly associated with patient rating of physician quality. Third, PCMH infrastructure measure was unrelated to patient-centered care measures. Final, PCMH infrastructure measure and patient rating of care quality rendered by their physician accounted for important but distinctly different aspects of an intermediate outcome quality measure (blood pressure [BP] control).