The simple reason the medical-home study failed…

This week, the Journal of the American Medical Association (JAMA) published a comprehensive study that has major health implications. Major because the negative findings should change how Americans think about health and healthcare. Plus, the findings validate a belief this doctor holds as truth.

First my belief, then the study.

One blog is enough for any practicing doctor, but if I were to start another, its name would be: “Health cometh not from healthcare.”

Nary a day goes by that I don’t see an example of how good-intentioned active management of a patient causes problems. (BTW: My son, a grammar prescriptivist, says I shouldn’t use that word, nary.) Emergency rooms overflow with elderly patients who have fallen because of BP goals. Last week, I saw a patient admitted (for confusion) with dangerously low sodium levels because of high BP treatment. It’s the same story with aggressive blood sugar control, statins in the elderly, NSAIDs, and we have already discussed the limits of screening for disease. The good-intentioned-but-harmful-treatment list is a long one.

The success of managing chronic disease does not turn on doctors or nurses. It turns on the patient and his or her choices. One of the wisest doctors in my hospital once gave me unforgettable advice: he said doctors don’t control outcomes.

The JAMA study: Screen Shot 2014-02-26 at 5.48.51 AM

Health policy experts believed that active management of patients with chronic disease would lead to better outcomes. The team approach is called the patient-centered medical home. Though a great idea on paper, an analysis of outcomes in this large pilot study showed no benefit on accepted measures of quality. More important, medical homes did not prevent hospital admissions and ER visits. (This, despite lofty bonuses paid to the doctors — $92,000.)

What an important lesson for everyone involved in healthcare.

For health policy people and doctors, this lesson should help redirect our efforts towards helping patients make better choices about their health. If we must measure surrogates, let’s measure simpler ones, such as weight, belt size and 5K walk time. Let’s be clear-eyed about something: when we substitute pills, tests and procedures for simple things like eating well, moving, sleeping and smiling, we risk making our patients worse.

For patients, the lesson here is that doctors can help treat problems that develop, and, we can teach you things about your body and health, but we can’t make you truly healthy. A teacher can’t do her student’s homework, a coach can’t throw the pass, and a doctor can’t stop you from eating potato chips.

JMM

Comments

  1. Steven Horvirz. D.O. says

    Nicely stated and the absolute truth. Problem is big brother wants to take over the world and when it acts that way individuals give up responsibility for themselves and blame big brother and it’s soldiers, which in healthcare are doctors, nurses, and other healthcare professionals.

  2. Bill Dailey, MD, MS says

    Could it be that the benefits of prevention don’t happen rapidly?

    This isn’t surgery, there are
    No overnight benefits.

    I suspect the patient AND the doctor need to do a better job.

  3. Michelle says

    I was diagnosed with Atrial Flutter 3 years ago this coming June. I was told to get my stress under control. Limit my sodium intake to 1500mg per day. Cut the caffeine, limit my water intake to 2 liters per day. Luckily I didn’t drink or smoke! Start walking 5 days a week, take my medicine as prescribed and keep all docotr appointments.

    I followed those orders because I believed that if I didn’t I wouldn’t be long for this world. When I started doing these things I was able to cut the blood pressure medicines, cholestrol in half. I also dropped 40 lbs.

    I am in pretty good shape for being a 68 year old female. The nurse’s told me one day that I was the type of patient they wished they had more of. If you go to a doctor why wouldn’t your listen to what he is telling you.

    I watch my friends who have high blood pressure, diabetes, high cholesterol take medicine and then eat and drink whatever they want. I just sit in utter amazement that they take the medicine and don’t adjust their lifestyles.

  4. says

    Would you please define the word “elderly.” I’m 61, spousal unit it 67. Are we elderly yet? It’s a surprisingly amorphous word. One wonders if there is a hard cutoff, or is it more a state of mind. Any clarity on this would be greatly appreciated. Your fourth paragraph is elderly specific, but it needs the underpinning of what constitutes elderly.
    I like the word “nary.” Why used two words when one will do.

    • says

      I hope Dr. John answers your question. I’m a geriatrician and I think often about who needs “healthcare for the elderly.”

      I agree w Dr. John that esp as people get older, the pills and procedures become risky. Much better if we can support people in taking care of themselves. Less medicine can be more well-being.

    • says

      Allison…The way I will answer your question about defining “elderly” is with these nuggets: 1.) I know it when I see it, and so do most experienced doctors. 2.) “A 90 year-old may look young, but when you cut them open there are still 90 rings.” 3.) People age rapidly after we do things to them — like giving drugs that affect cognition, sleep, blood pressure, kidney function, or, putting them under anesthesia, putting them in bed or putting them on exercise restrictions. Short answer: Chronological age is not the same as physiologic age.

  5. pgyx says

    Very well said! Your excellent blog gets better and better. I recommend it to patients and fellow docs.

    Kudos to Michelle for making such important lifestyle changes! I wish all of our patients followed her lead, tho’ many would no longer be our patients if that were the case.

  6. says

    Thank you for your post, but I am confused by your point. In several of the cases you cite, the patients experience problems because they are (from what you write) adhering to some treatment, usually for BP or diabetes. In the course of the BP control, for instance, the person becomes lightheaded/dizzy/falls. This has nothing to do with whether the person is also managing diet and other factors, and more to do with the effects of the medications? In these cases, it seems, clinicians would be wise to look at minimally disruptive medicine, and the work of being a patient. It is true that the doctor cannot do all of the work for a patient–but the treatments should also do no, or little, harm.

  7. says

    Nicely stated. “You can lead a horse to water but….” We are individually responsible for our health and need to ask for guidance on living a healthy life rather than “what pills do you have for that” as a first option.

  8. says

    Nice blog post. There’s another simple reason for the null finding. The premise around PCMHs is that coordinated care leads to better outcomes. Read the study carefully and show me the measure of coordination.

    There is none.

    Certainly there is a range of coordination. Some control practices will be unusually good at it. Some bad. Most average. Similar with the PCMHs. This means this is nothing to assure us that coordination is better in PCMH. We want to believe that because we applied the label of PCMH coordination is better, but there’s no way, yet, to prove it to me.

    I want to be able to stratify the analysis by a reliable and valid measure of coordination so I can compare high coordination practices to lower coordination practices.

    Till then we are examining the special powers of a label.

  9. says

    Of course it would be great if more primary care physicians were trained as educators, and got reimbursed for educating patients on self-care.

    “Health ed” was a horrid class in my high school, e.g. basic anatomy and memorization… Instead I now take my young kids to a L.Ac. who’s teaching them belly breathing, gut and immune function, and explaining how their inner “fire” is something to watch, control and use for good. :) We talk about nutrition, sunlight and exercise, and their spiritual nourishment.
    PS. I pay her $160 and take home a credit card receipt to reconcile with my bank account, in terms of “billing” and “claims paperwork”….

  10. says

    Admittedly the problem with the first generation of PCMH pilots (call them version 1.0) is that groups like NCQA, JACHO and other accreditation bodies seemed to write the “specs” for the medical home rather than medical professionals with experience managing “high performing” practices.

    But the ball game with respect to PCMH is only in early innings. Should PCMH proponents come to realize that it is the softer elements such as effective patient-centered communication skills (and not HIT or embedded care coordinators) that lead to better outcomes, lower costs and better patient (and physician experiences) we may still realize the promise of PCMH.

    Steve Wilkins
    Mind the Gap
    http://www.healthecommunications.wordpress.com

  11. says

    Well said Steve. It is very early days for PCMHs.
    It’s also early days in the definition of ‘coordinated care.’ I happen to agree with you that so-called softer aspects of care hold promise. The easier to monitor aspects that are currently measurable may be necessary but insufficient. This, I believe, helps make my earlier point – we do not yet know how to measure ‘coordinated care.’

  12. says

    Thom,

    There’s 30 years of evidence documenting the link between patient-centered communication skills (skills like visit agenda setting, eliciting the patient’s perspective, shared decision making, and yes care coordination) and measurably better patient outcomes, fewer lab tests, few ER visits and readmits and better doctor and patient experiences.

    In fact I am heading up a group called the Adopt One! Challenge that will be conducting baseline assessments of physician communication skills in exam rooms across the U.S. (including PCMH) to raise awareness of deficit of patient-centered communications among today’s physicians. Remedial skills training will also be a part of the Adopt One! Challenge.

    • Doctorsh says

      Communication between doctor and patient is key, especially when there are no third parties messing things up with bureaucracy.
      Patients must demand a medical home and they must be responsible for it. It should not be the responsibility of any third party be it govt, insurer, or even employer.

      • says

        Doctorsh,

        The concept of a medical home is often confusing to patients principally because they believe that their doctors are or should already doing (care coordination for example) what these new things call PCMH say will now start being provided.

        The shift to a patient-centered model requires a culture shift for clinicians and patients. Presently doctors function as the “experts” making decisions for patients and doing most of the talking. Patients for their part adopt the passive sick role (learned for childhood visits to the pediatrician) wherein they basis speak when asked to. Both sides need to adopt more engaged and collaborative role…and the impetus will need to come from clinicians initially.

        Having been socialized into this passive sick role it is unrealistic for most patients to “demand” anything of physicians. Why? They are too damn scared. They fear being labeled as difficult as pointed out in a recent qualitative study of well educated, affluent patients at the Palo Alto Med Foundation. And it this segment of patients is reluctant to speak up…imagine how hard it is for less affluent, less educated folks to speak up with their doctor. In other words..patients will not be leading the charge on this.

        • Doctorsh says

          Then it won’t work.

          Patients are the center of every interaction.
          Everything else should revolve around them.
          As long as govt or insurer bureaucracy is involved the interaction will be made more difficult and be destined to fail.
          Get the third parties out of it.
          Involve the patients more in their healthcare decisions.
          If they do not want to be involved, then no medical home will ever work, other than for the beam counters.

  13. says

    Great post. This “lesson” needs to be taught to North Carolina Medicaid, that continues to believe their PCMH (Community Care of North Carolina) saved a billion dollars even after the consultants from Miliman who did the study admitted lying. In reality, the PCMH was the major if not only factor driving North Carolina Medicaid’s costs far above that of neighboring states.