Patient-Centered Medical Homes and Appointment Availability for New Patients
Enhancing access to primary care is a key component of a patient-centered medical home (PCMH). But little is known about how PCMH status affects the availability of appointments for new patients. In a new analysis of “secret shopper” data, LDI Senior Fellows Jaya Aysola, Karin Rhodes and Daniel Polsky found that PCMHs were 1.26 times more likely to offer a new appointment and 1.36 times more likely to schedule an after-hours appointment than other primary care practices, with no differences in average wait time for a new appointment.
The data were collected in 2012-2013, prior to full implementation of the Affordable Care Act. Trained field staff placed more than 11,000 phone calls to more than 7,000 primary care practices across 10 states, posing as new patients seeking a primary care appointment. Previously, findings from the study showed differences in the likelihood of scheduling an appointment by type of insurance, and the important role played by federally-qualified health centers and rural health clinics in assuring appointment availability to Medicaid patients.
While just 5% of practices in the study were PCMHs, the difference in new appointment availability may take on increased importance as the model is more widely adopted and as millions of non-elderly adults gain coverage through the ACA.
Why might PCMHs have more new patient appointment availability than other practices? It could be simply because they make a concerted effort to make access to appointments easier, as part of their overall policies on enhanced access to care. Beyond this, the data are silent. Another hypothesis is that the efficiencies created by PCMH processes may allow for greater patient panel size. There is debate, however, on whether these efficiencies will instead be applied to improving the care for existing patients. The authors note:
Some believe that PCMH will expand panel sizes and assert that global payment schemes would naturally incentivize this over fee-for-service models. Others expect that PCMH practices will keep panel sizes low and increase the intensity of services provided to existing patients, by lengthening patient visit times to improve the quality of care and minimize provider burnout.
The study did find differences in average daily census per physician between PCMH practices and non-PCMH practices. Most physicians in both PCMH and non-PCMH practices saw an average of 20-39 patients daily, but fewer PCMH providers saw more than 40 patients daily than those in other practices. However, the study found no significant relationship between average physician daily patient census and access to new appointments, and so the question remains an open one.
The PCMH model: what we know
Patient Centered Medical Homes (PCMH) are primary care practices that are accredited by the National Committee on Quality Assurance (NCQA) according to a set of standards that focus on enhancing access and continuity of care, identifying and managing patient populations, tracking and care coordination, providing effective care management, self-care and community support, and measuring and improving performance.
The PCMH model is still in its infancy; the NCQA proposed operational standards for recognizing practices as PCMHs in 2008. Given the time needed for “practice transformation,” and the wide variation in performance on the scale that the NCQA uses to evaluate PCMH-certified providers, comprehensive and reliable evaluations have been difficult to conduct.
A 2013 systematic review found evidence of a small positive effect on patient experiences and delivery of preventive care services, but concluded that current evidence is insufficient to determine effects on clinical and most economic outcomes.
A recent study by Aysola and colleagues found that most patients enrolled in PCMHs within the University of Pennsylvania Health System didn’t even know that they were in a PCMH. Patients uniformly lacked awareness of the PCMH concept, and the vast majority perceived no PCMH-related structural changes, regardless of the degree of practice-reported PCMH adoption.
As the PCMH model spreads and evolves, and providers are able to move past meeting a list of standards and move toward meaningful transformation – in areas such as appointment flexibility, care coordination and remote support –more useful data on PCMH performance and outcomes should emerge.