Around 8:30 last night (a Sunday), the personal care attendant for one of my long-standing diabetic patients called me. I let it roll into voice mail-and then listened to it. Her sugar was 530 (normal is up to 100). I called her back, spoke with her for about 1 minute, made a clinical assessment that she could be managed at home (instead of going to the emergency department), texted her twice (taking up about 30 seconds), and over the next 2 hours brought the sugar down to 220, and this morning it is 116.
This interaction validates most of Professor Wasson's recommendations in this issue of the journal. It is appropriate that we devote an issue of the Journal in this 40th anniversary year to the theme of the patient-centered medical home (PCMH), the lynchpin of ambulatory care.
In today's payment and monitoring environment, I will receive nothing from this interaction other than the most important benefit-a positive outcome for my patient. No "visit" credit to add to my list of Evaluation and Management (E&M) codes; no recognition of the minimum of $10 000 I saved for the "health care system."
In describing this interaction with my diabetic patient, Professor Wasson identifies several of the key ingredients of a true PCMH. I've known my diabetic patient for 25 years. She felt comfortable contacting me. She had the confidence to know that something was wrong. Professor Wasson's What Matters Index could be very helpful in individuals such as her. I agree that we need only a small number of outcomes metrics. Just because there are many constituencies, each of which demands its own set of, typically, process metrics, does not constitute a sufficient reason to accept the literally hundreds of useless quality metrics that Centers for Medicare & Medicaid Services, NCQA, and The Joint Commission all are still demanding.
I would make 2 friendly amendments to Professor Wasson's critical observations, both of which are echoed in the generally supportive commentaries that follow his article. First, I do not believe that we have to make a choice between administrative versus patient-reported data. It is not either-or. It can and should be both-not just because of today's technology that permits easy linkage between these 2 types of data. Administrative data are also important, as they provide us with important information on the health care professional's perspective on the patient. Diagnosis can be very important, particularly as it pertains to complex diagnoses (a diabetic person on dialysis vs a diabetic person who is diet-controlled) and/or socioeconomic disparities of health (such as mental health diagnoses; eg, schizophrenia vs anxiety). Administrative data today do not just consist of diagnoses and procedures (which parenthetically can be easily tracked for important outcomes) but also consist of information, for example, on the health care professional's assessment of the functional status of the patient and the health care professsional's assessment of the housing stability of the patient.
My second friendly amendment is that we know that payment understandably motivates health care professionals. I generated no E&M codes with my text interaction with my diabetic patient. Most health systems-whether they are hospital-owned or physician-driven-still measure primary care physician performance on the basis of justly reviled E&M codes. Few health systems incorporate examination of waste or potentially preventable events despite the fact that several approaches are available. These approaches appropriately rely on the rich administrative data that are increasingly available.
While not part of the special issued focused on John Wasson's article, the other articles in this issue, highlight the many challenges and opportunities that exist for the PCMH. The VA study by Simonetti find that burnout among employees did not change after PCMH implementation. As Hung and colleagues highlight in another article that in part examines issues pertaining to burnout: readiness connotes being both willing and also able to execute change. As most (but not all) of the commentaries and John Wasson's article point out, ability to change the PCMH has little to do with the billions of dollars spent in the National Commission for Quality Assurance effort. Philipps highlights the importance of learning collaboratives, an important part but only part of what John Wasson and Rushika Fernandopulle believe is necessary. What is the end result of a TARP program as advocated by John Wasson? For sure we would find decreased avoidable hospitalizations. This can only happen if the lessons of articles such as by Wright and colleagues are taken to heart in a major re-do of the PCMH.
Who will fix the PCMH? It is up to ourselves as health care professionals to change the PCMH. A combination of professional societies such as the American Academy of Family Practice, the American College of Physicians among other groups, together with confident patients and empowered health professionals, is needed. This special issue of the Journal provides a robust path to go forward.
-Norbert I. Goldfield, MD
Editor