THE MILBANK QUARTERLY - American Academy of Family …...The Milbank Quarterly, Vol. 90, No. 3, 2012...

Off the Hamster Wheel? QualitativeEvaluation of a Payment-LinkedPatient-Centered Medical Home (PCMH)Pilot

ASAF BITTON, 1,2 GREGORY R. S CHWARTZ, 1,2

EL IZABETH E. STEWART, 3 DANIEL E .HENDERSON, 4 CAROL A. KEOHANE, 1 DAVID W.BATES , 1,2,5 and GORDON D. SCHIFF 1,2

1Brigham and Women’s Hospital; 2Harvard Medical School; 3AmericanAcademy of Family Physicians, National Research Network; 4ColumbiaUniversity Medical Center; 5Harvard School of Public Health

Context: Many primary care practices are moving toward the patient-centeredmedical home (PCMH) model and increasingly are offering payment incentiveslinked to PCMH changes. Despite widespread acceptance of general PCMHconcepts, there is still a pressing need to examine carefully and critically whattransformation means for primary care practices and their patients and theexperience of undergoing such change in a practice.

Methods: We used a qualitative case study approach to explore the underlyingdynamics of change at five practices participating in PCMH transformationefforts linked to payment reform. The evaluation consisted of structured sitevisits, interviews, observations, and artifact reviews followed by a structuredreview of transcripts and documents for patterns, themes, and insights relatedto PCMH implementation.

Findings: We describe both the detailed components of each practice’s transfor-mation efforts and a grounded taxonomy of eight insights stemming from theexperiences of these medical homes. We identified specific contextual factorsrelated to wide variations in change tactics. We also observed widely varying

Address correspondence to: Asaf Bitton, Division of General Internal Medicine,Brigham and Women’s Hospital, 1620 Tremont St., 3rd Floor, Room 3-002P,Boston, MA 02120 (email: [email protected]).

The Milbank Quarterly, Vol. 90, No. 3, 2012 (pp. 484–515)c© 2012 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

484

THE

MILBANK QUARTERLYA MULTIDISCIPLINARY JOURNAL OF POPULATION HEALTH AND HEALTH POLICY

Payment-Linked Patient-Centered Medical Home Pilot 485

approaches to catalyzing change using (or not) external consultants, specificchallenges regarding health information technology implementation, team andstaff role restructuring, compensation, and change fatigue, and several unex-pected potential confounders or alternative explanations for practice success.

Conclusions: Our evaluation affirms the value and necessity of qualitativemethods for understanding primary care practice transformation, and it shouldencourage ongoing and future pilots to include assessments of the PCMH changeprocess beyond clinical markers and claims data. The results raise insights intothe heterogeneity of medical home transformation, the central but complex roleof payment reform in creating a space for change, the ability of small practicesto achieve substantial change in a short time period, and the challenges ofsustaining it.

Keywords: patient-centered medical home, qualitative, primary care, pay-ment reform, evaluation.

Agreater understanding of ways to improve primarycare is one of our nation’s highest priorities for building a morehumane and cost-effective health system (ACP 2006; Crabtree

et al. 2011; Nutting et al. 2011; Rittenhouse, Shortell, and Fisher2009). Primary care physicians often speak of a desire to “get off thehamster wheel”—the phenomenon of having to see more patients forshorter visits and less pay (Berenson and Rich 2010). Several hundredexperiments currently under way are examining how primary care canbe transformed from traditional episodic physician encounters into whathas been termed the Patient-Centered Medical Home (PCMH), a modelthat emphasizes more comprehensive care coordination, care teams, andpopulation health management (Bitton, Martin, and Landon 2010).

It is important that we closely examine what is actually occurringin these PCMH experiments. The quantitative data collected from themyriad PCMH projects, while critical, tell only part of the story (Crab-tree et al. 2011; Gilfillan et al. 2010; Reid et al. 2010). Without anon-the-ground look at how these changes affect staff, patients, and workflow, we will lose the opportunity to understand how practices are beingtransformed (Berwick 2007).

Our evaluation is part of a larger assessment of PCMH implementa-tion models tied to payment reform in five primary care practices in two

486 A. Bitton et al.

states in the northeastern United States. We sought to better understandthe experiences of these practices as they transformed into medical homesaided by payment reform. Of particular interest was how they respondedto a new reimbursement opportunity based on a new, comprehensive,risk-adjusted payment model (Goroll et al. 2007). This model, in whichthere is widespread interest, centers on fundamentally restructuring thereimbursement for comprehensive patient-centered primary care in aPCMH environment. It eliminates fee for service (FFS), instead payingthe practice a risk-adjusted base payment per patient per month tosupport all the efforts by physicians and the team, plus the healthinformation technology (HIT) necessary for PCMH. The base paymentfor the first year was based on historic FFS trends for the practice,multiplied by a risk-adjustment formula, with an additional one-timerevenue boost. Physicians were paid a base salary using this monthlypayment system, supplemented by a substantial (up to 25%) “bonus”for achievements in cost-effectiveness, efficiency, quality, and patients’experience. To better understand how the five practices approached thisnew PCMH payment and practice transformation model, we conducteda qualitative evaluation consisting of site visits, interviews, observations,and document reviews.

Methods

Study Design and Sample

This PCMH pilot project began in 2009 with a self-selected sample offive primary care practices, each composed of a single office with three toeight physicians. The pilot’s design was based on the new payment modeland a proposal under the auspices of the Massachusetts Coalition forPrimary Care Reform (MACPR) initiative to test fundamental primarycare payment reform in the context of PCMH practice change. Thetransformation of three practices in one state was affiliated with a regionalpayer, the insurer for a significant percentage of the patients. The othertwo practices were part of an integrated multispecialty group in anotherstate. The design, length, and details of the pilot had been determinedbefore the start of our analysis.

As part of a larger detailed evaluation, we designed our qualitativereview to assess how the practices were actually carrying out the PCMH


transformation. Our core qualitative evaluation team was made up ofthree primary care physicians, a medical/public health student, and aregistered nurse, all with expertise in primary care redesign. Guided byan experienced qualitative researcher with an extensive background inPCMH data collection and analysis, we spent several months refiningour research questions and data collection methods (see table 1). We useda qualitative comparative case study approach to explore each practice’stransformation efforts and also to compare the practices linked to theregional payer with those practices in the multispecialty group. Weconducted the qualitative phase of the evaluation in 2010, after eachpilot site had been engaged in transformation activities for at leasttwelve to eighteen months.

Data Collection

We began collecting primary data in late 2010 and early 2011. TheBrigham and Women’s Hospital Institutional Review Board (IRB) re-viewed and approved the protocols for our primary data collection. Beforeour site visits, our team conducted semistructured interviews with theleadership of the five practices. Next, four or five clinical members ofthe evaluation team conducted a concentrated site visit at each practice.Each visit lasted four to six hours and followed a four-step process us-ing each team member’s notes to strive for data saturation (table 1). Aminimum of a dozen staff members were interviewed at each site (threeto six physicians or mid-level providers, two to five nurses, one to twopractice managers or administrators, and three to eight support staff).Verbal consent was obtained from each individual interviewed on-site.

Data Analysis

The evaluation team first transcribed notes individually and then col-lated and reviewed them collectively. We iteratively coded themes thatemerged from these notes over a series of weekly meetings, workingwith documentary and pictorial artifacts collected from the practice vis-its. Following the constant comparative method, we created groundedtheory insights (Glaser 1967). Using selective coding, we systemati-cally related the core category (transformational change) to emergingcategories and insights related to change (Strauss 1990), for exam-ple, the genesis, challenges, successes, sustainability, and underlying


TABLE 1Site Visit Methods

Format Purpose

Step 1 Large group meetingwith senior staff andproject leadership

Pose general questions to group toevoke overall issues, stories,time frame, and themes (60min)

Step 2a In-depth interviews withkey informantsa

Probe into change process to elicitgranular details, illustrativevignettes, and maximumcandor (60 min apiece)

Step 2b Semistructuredinterviews of frontlinestaffb

Confirm, revise, or disconfirmdata based on previousinterviews; generate new data;triangulate to allow multipleperspectives (30 min apiece)

Step 3 Direct observation ofpatients’ paths andwork flow

Confirm or disconfirm interviewdata with observation; conductobservation in multiple areas ofthe practice by four observers toallow triangulation (90 min)

Step 4 Review of practiceartifacts anddocumentsc

Generate insight into practiceself-perception, attributes, andimplementation (ongoing)

Domains of Inquiry Examples of In-Depth InterviewQuestions

• Basic model/plan for change: generalgoal and approaches

• Practice transformation features:specific changes, why they werechosen, time frames

• Team/cultural changes: roletransitions, reconfiguration of staffmodels

• Role of electronic health records,clinical decision support, and otherhealth information technologychanges

Think back to your perspective onthis project in the beginning,and think about it now. Whatis different?[Followed by probe] Tell memore about the feeling that thiswas your last option?

In thinking about the newpayment model for yourpractice . . . how did the notionof incentives change behavior?[Probe] Tell me about the

Continued


TABLE 1—Continued

Domains of InquiryExamples of In-Depth Interview

Questions

• Population management versuspatient-by-patient care

• Patient flow and case managementchanges

• Overall experience andperspectives: successes, failures,challenges, unexpected lessons

• Expansion of model to otherpractices; feasibility ofsustainability

• Protocols and perceptions offinancial restructuring

reactions or behaviors of specificstaff at various levels.

Let’s think about how roles in thispractice may have changed overthe course of the project. [Probe]You say it now seems like you’redoing more work while others aredoing less. Tell me more aboutthat.

What has been your experience thusfar with team-based care? [Probe]You say you now see only thesicker patients while your nursepractitioner sees the healthierpatients. What is that like?

Notes: aPhysician leadership and other senior staff.bPhysicians, mid-level providers, nurses, care managers, medical assistants, and administrativestaff.cInternal practice transformation plans / performance metrics, QI goals, and care redesign protocolsand instruments.

organizational framework of the practice. Our overall goal was to gen-erate a series of grounded insights that would be generalizable to otherpractices undergoing transformation attempts and also be useful to pay-ers and policymakers guiding medical home and primary care reform.Whenever possible, we attribute quotations to practice sites, but be-cause of individual confidentiality agreements, we were not permittedto identify the particular person.

Results

Practice Descriptions and Changes Implemented

Table 2 describes the baseline practice characteristics and regional de-mographic information, and table 3 summarizes the genesis of practicechange and the specific strategies used to implement the PCMH andpayment reform models. The practices differ in the impetus of and


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rmat

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care

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mit

atio

n:P

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chan

geto

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EH

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2011

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tifu

ncti

onal

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elop

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trat

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ocol

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plex

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dea

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plet

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form

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gew

ith

hosp

ital

s. Con

tinu

ed


TAB

LE3—

Con

tinu

ed

Aff

ilia

ted

wit

hR

egio

nalP

ayer

Inte

grat

edM

ulti

spec

ialt

yG

roup

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ctic

eA

Pra

ctic

eB

Pra

ctic

eC

Pra

ctic

eD

Pra

ctic

eE

Pra

ctic

ewid

ech

ange

sIn

itia

ted

regu

lar

staf

fm

eeti

ngs.

Per

form

edpr

evis

itw

ork,

incl

udin

gpo

pula

ting

med

ical

reco

rdno

tes

wit

hpa

tien

ts’i

nfor

mat

ion

befo

revi

sit.

Eli

min

ated

phar

mac

euti

cal-

spon

sore

dlu

nche

sto

prom

ote

mor

eco

st-e

ffec

tive

gene

ric

pres

crib

ing.

Cha

nged

appo

intm

ent

sche

duli

ngte

mpl

ates

toin

crea

seac

cess

.E

mpo

wer

ednu

rses

totr

iage

pati

ents

,run

prot

ocol

sfo

rst

rep

phar

yngi

tis

and

urin

ary

trac

kin

fect

ions

,an

dm

anag

ean

tico

agul

atio

ncl

inic

.

Ret

rain

edst

aff;

none

wst

affh

ired

.M

oved

one

RN

from

fron

tlin

ete

leph

one

tria

gew

ork

todo

case

man

agem

ent.

Focu

sed

onpo

stdi

scha

rge

foll

ow-u

pfr

omth

eem

erge

ncy

depa

rtm

ent.

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oved

pati

ents

’ac

cess

toca

reby

open

ing

anX

-ray

imag

ing

cent

eron

-sit

e,an

dal

low

edaf

ter-

hour

ste

leph

one

call

sto

avoi

dun

nece

ssar

yE

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dsp

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list

refe

rral

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min

ated

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nche

s.Im

prov

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inpa

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ase

seve

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ade

min

imal

othe

rst

affi

ngch

ange

sor

new

hire

s.

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iate

dda

ily

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hudd

les

(mee

ting

s),

wit

hfo

cus

onim

prov

ing

proc

esse

ssu

chas

tele

phon

eca

llre

spon

sera

tes.

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ivel

yso

lici

ted

sugg

esti

ons

from

all

team

mem

bers

.B

ette

rjo

bro

lede

scri

ptio

nsan

dta

skas

sign

men

t,w

ith

publ

icly

disp

laye

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adli

nes.

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phas

ized

proc

ess

rede

sign

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orpo

rate

das

sidu

ous

proc

ess

mea

sure

men

tan

dvi

sual

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lay

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sult

son

wal

lsof

the

clin

icto

open

lytr

ack

team

prog

ress

.

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edsi

gnif

ican

tnu

mbe

rof

new

med

ical

assi

stan

ts.

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ease

dsc

ope

ofca

refo

rR

Ns

and

hire

dne

wnu

rse

prac

titi

oner

s.C

onve

ned

rapi

dim

prov

emen

tse

ssio

nson

pati

ent

flow

and

tele

phon

etr

iage

.

Con

tinu

ed


TAB

LE3—

Con

tinu

ed

Aff

ilia

ted

wit

hR

egio

nalP

ayer

Inte

grat

edM

ulti

spec

ialt

yG

roup

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ctic

eA

Pra

ctic

eB

Pra

ctic

eC

Pra

ctic

eD

Pra

ctic

eE

Poi

nt-o

f-ca

rech

ange

sfo

rpr

ovid

ers

Cre

ated

prel

imin

ary

“pop

ulat

ed”

note

sw

ith

info

rmat

ion

(suc

has

prob

lem

s,m

edic

atio

ns,

alle

rgie

s,et

c.)

befo

revi

sit,

toco

mpl

ete

note

squ

ickl

y.Fo

cuse

don

achi

evin

gch

roni

cdi

seas

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sth

roug

hpa

yer-

prov

ided

chro

nic

dise

ase

perf

orm

ance

shee

ts.

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dda

ily

“vir

tual

min

i-hu

ddle

s”(i

.e.,

brie

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star

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ical

sess

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ork

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prov

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isit

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and

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(e.g

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tes

befo

revi

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and

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gen

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-vis

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ndou

tsaf

ter

visi

t).

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dch

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cdi

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min

der

and

lab

valu

esh

eets

(pro

vide

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com

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cial

vend

or).

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igne

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sem

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phas

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evel

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MA

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e-an

dpo

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sit

role

sin

prep

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and

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Hel

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een

visi

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leph

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outr

each

topa

tien

ts.

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ated

syst

ems

toal

ert

team

topa

tien

ts’n

eeds

earl

y,su

chas

undi

agno

sed

HT

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sici

ansc

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shif

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dres

spo

pula

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man

agem

ent.

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itut

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yad

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odel

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ith

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fice

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atre

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med

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reco

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iati

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oth

befo

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),to

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and

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erro

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).Ta

rget

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for

chro

nic

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agem

ent

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onH

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and

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com

posi

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valu

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the

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issi

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Con

tinu

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TAB

LE3—

Con

tinu

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ilia

ted

wit

hR

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grat

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ted

rate

for

each

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ent

attr

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edto

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r(t

houg

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dbe

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etr

ansf

orm

atio

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arm

acy,

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pati

ents

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ctic

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ents

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ath

resh

old

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atie

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rien

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p-fr

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sfor

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supp

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labl

eto

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ream

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organizational structure for the transformation. A large regional in-surer sponsored the transformation of practices A, B, and C through anew payment model, and it also funded an external consultant to helpthem implement the changes. These practices were much less integratedthan practices D and E, which underwent transformation using internalfunding, in part based on their already high level of capitated contracts.As demonstration sites for a highly integrated multispecialty group,practices D and E used well-developed internal consultative and col-laborative resources to inform their transitions. Despite the short timeframe of twelve to eighteen months, all five practices made many andextensive changes. Table 3 illustrates the large variety of these differ-ent change processes and provides the context and background for eachpractice.

Grounded Taxonomy of Insights into MedicalHome Transformation

In this section we present some of the insights from these practices’ expe-riences in transforming to medical homes, which are based on interviews,observations, and analysis by our evaluation team. These insights werederived from eight key thematic areas that emerged from our field notesand discussions. While these overlap somewhat with recurring themesin PCMH design and literature, we chose as our starting point what weheard and saw rather than what others have written. We organized theseinsights and observations around representative quotations from our sitevisits, which we attribute to practice sites when possible.

The Context: Unique Circumstances Launched These PCMH Pilots. Be-cause the genesis and generalizability of these medical home experimentswere our main interest, we sought to understand their historical contextand the impetus that led to them. Most of the practice leaders told ushow they encountered what they dubbed “the Goroll model” (Gorollet al. 2007), which spoke to their concerns and needs. As one of thephysician leaders in practice A stated,

We were dying on the treadmill, trying to run faster and faster. Ifigured I could either become a dermatologist or buy a bowling alley.Then I saw the Goroll article, and we had him come out and we wereready to go; couldn’t believe how perfect it was, but what we didn’trealize was the depth of the change involved.


Meanwhile, and ironically, the coalition’s plans for a larger, multisitetest of the Goroll model encountered problems with its implementation.Mainly because of the multipayer nature of the U.S. health system,competing insurers who repeatedly voiced support for the medical homemodel and the needed financial reconfiguration were unable to agree withone another on the design of a multipayer pilot plan. As a result, plansfor a larger pilot floundered, as interested practices could not see a wayto build a medical home for just the few patients represented by any oneinsurer. Then a large regional payer and large integrated multispecialtygroup offered to invest in testing the model in five practices across twostates. As the large payer funding the transformation of practices A, B,and C observed,

Even though only 45 percent of the practices’ patients were ours, wefully bonused the providers [for 100 percent of the patients] and didnot prorate based on the number of our patients versus others.

Even though these two organizations supplied financial support tolaunch these ambitious medical home projects, according to intervieweesat the practices, the investment came with expectations that resultswould be demonstrated fairly rapidly. The special nature of the eventsleading to the pilot’s creation raises questions about how such projectscould be initiated and sustained in the future without more unified andsustained approaches to payment reform.

Wide Variations in Implemented Changes. In just these few practices,we observed significant variations in the changes implemented in thename of “medical home” transformation. As table 3 shows, the changesand approaches overlapped only occasionally. A person at site B describedhow:

We did not hire any new people specifically for this project. We lookedat what are doctor things, nursing things, clerk things, and tried tomake sure they were each just doing those types of things. . . .

Meanwhile, practice E reported that it had hired several new medicalassistants (MAs) in order to completely reconfigure the practice’s basicwork team structure based on a model of one physician to one MA.


Furthermore, some practices concentrated on reengineering between-visit and population management activities (i.e., calling patients ondisease registry lists), while others concentrated on changing the workflow and content of clinical encounters. Although this dichotomy was notabsolute, the divergence was noteworthy. Yet both groups described thesecontrasting efforts as aiming toward converging ends. Some practicesworked obsessively to drive out waste and create efficiencies to freeup staff and resources for more chronic care and proactive populationmanagement. Others focused on outreach, seeking to avoid preventableclinical encounters, thereby allowing physicians to accept new patientsor spend additional time with more complex patients. About the payer-sponsored initiative, one physician remarked:

We thought good operations could create capacity, and we could thenreinvest this for the non–face-to-face aspects of care, to reinvest thisinto better chronic care. But it turned out that there was a limitlessamount of work, and we’re not sure if we really made a dent in theamount of work by the efficiencies that were created.

For others, such as those in practice D, the process reengineeringseemed to be beginning to show benefits by the time we visited, partic-ularly in areas such as streamlining telephone triage and using nurse-ledprotocols to adjust hypertension and diabetes medications. By measur-ing and fine-tuning these processes, this practice reported that it wasshowing efficiency gains, thus enabling it to free up staff time for betterbetween-visit wellness care.

We call every patient, arrange for reliable follow-up appointments,and reconcile medications over the phone. Patients are very happy tohear from us, and we are able to identify and fix medication errors,which we found in roughly one in ten patients.

Catalyzing Change: Varied Use and Value of Consultants. Each prac-tice that worked with consultants reported a different experience, eventhough most worked with the same consulting company, TransforMED,the Medical Home implementation consulting arm of the AmericanAcademy of Family Physicians (AAFP 2012). The LEAN method ofreengineering process improvement, first popularized by the ToyotaProduction Systems (Chalice 2007), was also cited as integral to thetransformation of sites D and E. In each practice, the consultants


were paid by the sponsoring regional payer or the overarching groupentity.

We could not have done this without the help of TransforMED.They had a huge hand in getting everyone around the table, teach-ing everyone to work through processes, start to finish. Their trainerwas the voice of reason with MDs; she really helped us in build-ing consensus. She taught us the language and kept us going.(Practice A)

TransforMED stimulated this tremendously. We now think of patientswhether or not they are physically here. This is a change for us. This,plus team building—that was another important change. They werelike a parent. We loved and needed them, even though at times wedidn’t think we were ready for their advice. (Practice B)

We disengaged from TransforMED. We’re not a one-size-fits-all, not acookie-cutter office. We did work with them for five to six months butconcluded we already know how to manage our own office. We did notneed their guidance, and they were wasting our time. TransforMEDworks with practices with major problems. We already have highsatisfaction and were doing well financially. (Practice C)

We invited a person from TransforMED in who spent three days withus, but [we] found it was not that helpful. He told us what we alreadyknew. Instead, and by perfect coincidental timing with this project,we discovered LEAN. LEAN approaches allow us to make changesin a more structured way. By involving everyone in looking at thecurrent state data, the mechanics of LEAN allowed us to build ourprimary care medical home. (Practice D)

We started our PCMH project using a LEAN initiative approachfrom the beginning. We had some help from one of their consultantgroups, but mostly we are not really relying on outside training andconsultants. This is because we already had a fair amount of localexpertise as well as organizational help from our central office whowere experienced with LEAN. (Practice E)

Each of the practices commented on the role of and need for externalfacilitation and support to implement PCMH. All but one of the prac-tices clearly recognized the need for a both well-formed and prespecifiedchange model, as well as a road map to make the changes.

We found that some (but not all) practices funded by the largepayer embraced using external consultants to drive internal change,whereas those in the multispecialty group were more interested


in nurturing internally driven culture change. The two multispe-cialty group practices stated that the LEAN process was essential totransformation:

We could not have accomplished these changes without LEAN. Re-manufacturing primary care required us to use a variety of LEANconcepts and tools, such as load leveling, detailed standardization ofwork [e.g., a nine-page hypertension management protocol], visual-ization for transparency via tools such as huddle boards and cue cards,“just in time” processing, and one-week rapid improvement teaminitiatives. (Practice D)

Health Information Technology: Ubiquitous but Challenging. The roleand necessity of information technology (IT) and electronic healthrecords (EHR) are areas of intense interest, development, and contro-versy in transforming primary care (Bates and Bitton 2010; Schiff andBates 2010). In fact, IT systems and information interoperability toppedthe list of issues highlighted by staff during our site visits. We groupedour observations into four areas paralleling key IT functions and inter-ventions: (1) enhanced EHR use for reengineering clinical encounters,(2) interoperability challenges in information flow across care transi-tions, (3) population management and chronic disease outreach initia-tives, and (4) patient portals (online applications that allow patients tocommunicate with their health care providers). In each area, we docu-mented examples of both great satisfaction and great frustration.

Our MAs help start my notes before the visit. My notes are now doneby the time I hit the parking lot. [Notably, another MD in the samepractice described not being able to make this work for him.]

By pairing each of us with a MA and standardizing tasks done bythe MA before the physician enters the room [including updating theproblem list, medication reconciliation, immunizations, starting thenotes, reviewing/entering lab results, in addition to usual vital signrecording], we restructured each person’s responsibilities to get thebest flow.

This EMR has better messaging, templates, and smart phrases thanseveral of the others I have used. It’s a mature EMR, and as a matureEMR user, I am able to take advantage of it to finish my notes so Idon’t have to do them at home.


A majority of the practices already had mature EHR implementation(more than five years), and we found evidence of a continuous learningprocess to push the functionality in using templates and teamworkcollaboration (e.g., templates for the MA to update medications andfamily history). However, the majority of physicians we interviewed stillspent up to two hours at home in the evening completing or preparingnotes.

These physicians expressed their desire for PCMH transformation toease their charting burden, which was a major quality-of-life and practicesatisfaction issue in primary care.

Another recurring theme related to the practices’ efforts to ensure thetimely identification and collection of summaries from hospitalizations,emergency department visits, and rehabilitation hospital discharges. Atsite A, a large percentage of two nurses’ time was devoted to rounding uphospital discharge summaries, necessitated by the lack of interoperableinformation exchanges between various hospitals and the practice’s ITsystems. Even automated notification of the discharges, which practicesA, B, and C could have found in their insurer’s billing reports, failedto overcome this need for more manual efforts because the reports wereneither timely nor complete. Inpatient discharge summaries were par-ticularly challenging, with patients spread over a half dozen neighboringhospitals.

Notably, practice C, with arguably the least developed informationinfrastructure, had one of the most effective systems for obtaining re-ports, partly because of an interoperable health record connection withthe two main hospitals serving their inpatients. Practice C also relied onits affiliated group practice’s central office, whose IT specialists collatedbilling and clinical data, which was formatted into useful chronic diseaseperformance reports and fed back to the practice each day. By convert-ing a relative weakness to a strength (delegating various IT functionsto the central office), this practice provided an interesting model forovercoming its IT hurdles.

Although each practice had patient portals, their penetration variedonly from zero to 17 percent of their patients. These portals were clearlymore in the germinating than the fruit-bearing stage, even for thosepractices reporting fully functional portals:

Our portal, based on our commercial EMR, has been tremendouslyuseful and is a huge time saver. However, I find email is much quicker.


I love being able to quickly communicate with patients via e-mail,as opposed to phone, which can really slow me down, as the patientwould end up saying “oh, by the way,” and raise many peripheralquestions that I would have to answer when I was calling to give theirlab test results. (Practice D)

While this statement raises further questions (what are all these unan-swered questions and who should, and how best to, address them), itdoes point to the issues in using information technology to improvework-flow efficiency and quality. Efforts to deploy IT in medical hometransformation are in their infancy and may be missing the mark inimportant and needed ways (Bates and Bitton 2010; Schiff and Bates2010). This concern is illustrated by a quotation from one of the moreIT-advanced of the three sites in the large payer-funded pilot:

We were paperless when our PCMH project started. But now it’sall paper, we’re drowning in paper. We are now collecting previsitinformation on paper forms; billing used to be paperless, and nowsuperbill is all on paper. We have boxes of paper piling up withbacklogs of un-entered data.

Finally, we note the summary conclusion of one physician in practiceD. Standing in marked contrast to depictions of physicians as resistersof new IT, he expressed the practice’s desire for more and better systems:

Our biggest frustration is with the technology; we find it can’t keepup with our ideas.

Teams and Teamwork: Reengineering Roles and Care. Although we werenot surprised that the issue of teams and teamwork was central to thesepractices’ self-conception of PCMH, we observed that the meanings anduses of these seemingly simple words varied widely. To some, the termPCMH referred to the small working unit (or “teamlet”) (Bodenheimerand Laing 2007), particularly in practices with teams consisting of oneMA paired with one physician. The word team was also frequently usedto refer to the overall practice that was forging a new culture embodyingcollective PCMH principles:

This conference room where you are sitting is ground zero. Our team,which is comprised of all members of the practice, gathers here every


two weeks to discuss and redesign our practice. Extraordinary thingshappen in these team meetings; last week my MA presented my threeworst controlled hypertensives; it was embarrassing, revealing, andamazing that we could have such a candid discussion. (Practice E)

A third use of the word team was in reference to performance improve-ment teams. Practice A, which was described by the sponsoring healthplan as the “poster child” of multidisciplinary teamwork, created a seriesof functional teams:

We put together a series of six teams: a care coordination team, acommunication team, a scheduling team, etc. These teams were verymultidisciplinary, and we designed them to especially include supportstaff to make sure they broke down rather than increased silos.

The two practices in the multispecialty group (D and E) createda different series of teams, using LEAN strategies to perform formal“rapid improvement events” (RIEs):

We have now completed four RIEs, where we take people off theirjob for an entire week to reengineer a specific work flow. We do thesequarterly, and so far we have (or are planning) RIEs for the referral pro-cess and their cost-effectiveness, scheduling template reconfiguration,no-shows.

While the positive energy and a number of important measur-able accomplishments were evident, we recorded other, more soberingcomments about change improvement teams in both the less integratedand more integrated practices:

By appointing all these functional teams early, we found it hardto get and keep them all going at once. This led to considerabledisappointment and frustration for those on teams that did not meetor do much for the first year. (nurse, site A)

The RIE related to scheduling and reconfiguring the schedules inthe computer was not successful; it was actually a big mess. Oneperson had all these good ideas, good in theory, but they just didn’twork out. We couldn’t quite get the templates to work, particularlyaround scheduling routine physicals; we kept getting way behind inour work. (physician, Site D)


Finally, rather than teams, one practice in the large payer group(practice C) evidenced a more top-down, traditional approach to changeled by the practice’s lead physician and owner:

We didn’t change a thing in the way we organized things.

This practice was noteworthy for its more hierarchical leadership ap-proach and relative paucity of discrete teams, as well as its accomplish-ments. Remarkably, in early health plan data on efficiency and improve-ment, this practice stood out for its increased composite index efficiencyscore (whereas the two counterpart PCMH pilot practices showed littlechange, according to unpublished data collected by an insurer), raisingseveral intriguing questions. Could more top-down approaches be moreefficient and effective for short-term impacts? What effects would thishave (or not have) on fostering the teamwork relationships needed forlonger-term sustainability?

Compensation Reorganization: Centrality and Indifference. Compensa-tion reorganization was the central focus for both these five pilots andour interest in understanding how compensation change would affectthe PCMH transformation experience. Each group had an elaborate re-imbursement reconfiguration plan based largely on the Goroll model(Goroll et al. 2007) and other established pay-for-performance schemes.Two recurring observations were evident in all five sites. The first is thephysicians’ self-stated indifference to and ignorance of the schemes andtheir details across all sites:

They are studying this for economic reasons, but I am doing it forother reasons. Even though I am not making my bonuses or any moremoney, I am happier.

I have heard about reimbursement changes but don’t really knowanything about what it is about. We know there is pressure to dobetter, but we don’t really know much more about it than this.

Whether I am paid more money or not matters little to me here. Moremotivating than any bonus is [my] ability to provide more rational,high-quality care.

New compensation formulas? I never thought about it. Lifestyle ismore important than paycheck. I would rather have control overmy day.


While such statements may have been influenced by a social de-sirability bias (desire to sound less motivated by financial incentives),their consistency, sincerity, and depth were noteworthy. As one practiceleader pointed out, “Maybe these physicians would be feeling differ-ently if their incomes were declining.” However, there were a numberof examples of sticks (reimbursement hold-backs) in addition to thevarious carrots (base salary boosts, modest extra compensation for timespent on activities beyond face-to-face encounters) built into these pilotplans, suggesting that the real interest and focus was not just on theirincome.

We also noted some confusion between these new PCMH compensa-tion schemes and the shifting landscapes of fee-for-service and capitationreimbursements. A number of these practices historically were part ofstaff model HMO groups before shifting back to fee for service; for thesephysicians, the “hamster wheel” was synonymous with fee-for-servicemedicine. Others had a more nonspecific appreciation that reconfig-ured reimbursement could somehow make shifting away from exclusiveface-to-face encounters more financially viable:

We have long experience with capitation. The payment world that welive in permits us to take risks. It allows us to take a risk to decreasereliance on encounter visit–based revenue.

We welcomed the opportunity to get off the RVU [relative value unit]hamster wheel where we have to see more and more patients just tokeep up our productivity.

The hardest thing for us is that we have legs in two worlds, FFS [feefor service] and capitated. In the fee-for-service world, we don’t getpaid for these patients if we don’t bring them in the office.

The payer sponsoring transformations in practices A, B, and C wasclear that such jump-starting investments were required but also wasanxious to show a return to its board to justify the investment:

Our approach was different: we always were concerned with economicsand its critical role driving practice reform versus the more prevalentmodel that posits that practice reform would in turn drive the dollars.


We have a fair amount of money on the table. For our board, thisis the centerpiece. They’re expecting real deliverables. We investedheavily in increasing the nursing and other staff to MD ratios.

What about the nonphysician staff? We explored the ways that anyfinancial rewards were structured to include, or exclude, them, as wellas to learn their overall reactions. The five practices used five differentapproaches, with several turning out differently than planned.

It wasn’t just the MDs that were compensated, but [it] was trickyto figure out how, and thus we never really formally structured thatpart. It does somehow trickle down to rest of the staff, but they don’tcount on it or expect it.

If we meet our four target goals across the organization, everyone willshare in the bonus.

At every level of staff, there was a level of bonusing. Each could get anextra 5 percent, but despite this, we couldn’t get anybody’s attention.It wasn’t motivating at all—not at all effective.

We wanted to include nurses in the bonus reward plan, but difficul-ties arose with the nurses’ union—and there was a big cultural battleamong the nurses. “That person doesn’t deserve to get more than Iam getting.” Although the union eventually came around, the nursesthemselves couldn’t reach a consensus, and the plan was never imple-mented. As one of the nursing professionals working hard to makeimprovements, I resent that it couldn’t be worked out so I could havegotten a bonus I feel I deserve.

Pace of Change; Effects on Staff. There was visible tension betweengoing too slow and pushing too hard and fast. We observed the self-awareness and honest acknowledgment of this balance to move fast butto try to avoid change fatigue. This was particularly evident in efforts topush staff to work more at the “top of their training” skill level:

We found we were going too slow and losing the staff’s interest.Many of the people were excited to get appointed to the teams, yet itwas hard to get all the teams mobilized early enough, and many gotdiscouraged because they did not seem to be involved.

We touched every point of the PCMH model. We now recognizethat we tried to do too much too fast. Change is energy consuming,and we were trying to do a lot of things at the same time. At one


point we witnessed twenty nurses and support staff driven to tears;our consultants said we had to stop for a while to catch our breath.

Change fatigue was a big challenge for us—it was like an up-and-down roller coaster.

We had to keep adjusting our pace along the way. But when [we]wavered in commitment, the nurses wouldn’t let us stop.

One change featured in both the PCMH literature and the observedpractice transformations involved using the skills and time of nurses andMAs to maximize what they and the practices could accomplish. Thiswent beyond merely relieving physicians of clinical and clerical tasks,although some changes did entail shifting work away from them. Totake on new tasks, they adjusted the quantity or quality of existing taskson nurses’ and MAs’ plates. Most often, the practices and relevant staffmade such adjustments effectively. But we also found examples in eachpractice in which this tension was not addressed to the staff’s satisfaction.A dramatic example—one we almost missed (revealed to one memberof our team only during the observation period and later confirmed byothers)—was from a nurse in a practice that had seemed to be a modelof collaboration and teamwork.

There has been major pushing back all along; the support staff feelstotally overloaded. RNs’ roles have undergone a 180-degree change.We were hired as phone triage nurses. Now we are doing morechronic disease management and face-to-face triage—jobs we findmore satisfying—but we still have to do much of the phone triage inaddition to these new roles. This is not sustainable for us.

We uncovered another change fatigue variant: staff tiring of practiceprocess transformation meetings that overrode more traditional contin-uing education, for which they still yearned. According to a physicianin practice D,

Now we only meet to discuss project activities, since there are somany of them. There is no time for medical speakers; there is no lifeof the mind any longer, just not enough time. We don’t even have thetime to talk with the specialists like we used to.


Hidden from View: Findings Confounding Interpretation of the PCMHPilots. Our evaluation team observed a number of potentially con-founding events and factors, including major concurrent EHR shifts, theopening of new offices, wholesale changeovers of staff, new non-PCMHimprovement programs, changes in insurance coverage and plans, andcoinciding economic recession. These factors may make it more difficultto attribute changes in outcomes simply to the payment-linked PCMHtransformation.

For example, we learned from one practice’s billing staff that many pa-tients were refusing to come for tests and appointments because the area’slargest employer had recently shifted many employees to a health planwith an annual deductible of several thousand dollars. Meanwhile, thepilot data showing large decreases in the utilization of expensive drugsand imaging tests had been largely attributed to new, more cost-effectiveordering policies associated with PCMH-related staff education. In prac-tice E, we found that the practice site had been recently founded withboth self-selected and hand-picked staff, which roughly coincided withthe launching of the PCMH initiative. While we were impressed at thespecial commitment of these staff, this practice’s experience may be lessgeneralizable for more established practices engaged in transformation.

A final surprising finding was seeing a Medicare patient beingturned away at one practice after being told, “We no longer take newMedicare patients.” Efforts to analyze risk-adjusted chronic diseasemanagement processes and outcomes in elderly patients surely will beconfounded by such a policy, of which the research team was not previ-ously aware. These examples help illustrate the difficulty of interpretingisolated clinical and claims data without any knowledge of unintendedor concurrent changes that contextualize those data.

Discussion

We evaluated five practices participating in a coordinated PCMHdemonstration project linked to payment reform using observationalqualitative methods, and we found a rich variety of approaches, changes,successes, and frustrations. Our finding of complex (and, at times, con-tradictory) experiences affirms the need for qualitative evaluations to bet-ter understand where, whether, why, and how certain practices achievePCMH-related change. Our data suggest that such evaluations are also


needed to identify potential confounders, as well as to understand theexperiences of staff undergoing rapid change. Finally, our observationsallowed us to spotlight more implicit tensions and questions, issues thatmust continue to be raised and addressed if PCMH is to be a viablehealth reform strategy.

As Berwick emphasized, these “stories beneath” open important win-dows into the “mechanisms” and “context” vital to understanding qual-ity improvement efforts (Berwick 2007). Likewise, we believe our find-ings demonstrate that such stories are important to achieving the insightsand accountability needed to carefully evaluate groundbreaking pilots.

The first noteworthy finding of large variations in starting points,approaches, and interventions, while hardly unique to these PCMH pilotpractices, cannot be overemphasized (Nutting et al. 2011). Even witha well-defined model, external facilitation, and standardized PCMHcriteria, there were large differences among the practices in the samenetwork and even greater variations among the networks in our study.The varied application and mixed transformation successes observed inthese pilots cannot be fully captured by check boxes on a medical homescorecard.

A fundamental question raised by these wide variations is: What isa medical home? Is it a smorgasbord of different change tactics underthe general rubric of making primary care practices more patient cen-tered, proactive, efficient, and cost-effective? Such a broad frameworkmaximizes flexibility but presumes that any improvements in thesegeneral directions have value and ultimately will lead practices to morefully embody medical home principles and attributes. Or does PCMHtransformation require more standardized models that systematically en-sure that specific practice changes are made? Our observations suggestthat the five practices worked more in the smorgasbord mode and areunlikely to emerge from the PCMH transformation with similar fea-tures in place. To the extent that this is also true for other medical homeimplementations, it raises questions about comparing and interpretingfindings across the hundreds of projects currently under way. Nonethe-less, if the evaluations do show gains in patients’ experience, efficiency,and quality, this suggests that there may be many possible routes andmodels for improving primary care through the medical home model.Furthermore, it suggests that adaptive local variation and innovationwith the means to achieve this change are both permissible and perhapseven laudatory.


At the very least, these variations can help inform a priori hypothesesfor larger quantitative analysis, pointing to areas where we might ex-pect and explain improvements (or the lack thereof) among these fivepractices. For example, practice A stood out for its focus on postdis-charge follow-up efforts, dedicating two nurses to ensure that everydischarged patient was called and given a follow-up appointment, anactivity we will be evaluating as we measure and compare readmissionrates.

A second important finding relates to staff perceptions and mech-anisms regarding the new financial payment formulas, which was ofparticular interest in these five pilot sites. Unlike earlier demonstra-tions, these five projects were explicitly based on practice change linkedto novel compensation reform, including an elaborate, risk-adjustedmethod for practice and practitioner reimbursement. To the extentthat PCPs are—as has now been well documented—spending largeportions of their day performing vital but un-reimbursed patient caremanagement activities, more rational and outcomes-aligned models forreimbursement are essential (Bodenheimer 2008). The “hamster wheel”metaphor was frequently invoked by the physicians in our study todescribe prepayment reform practice. But here, the reformed paymentmodel was less an individual motivator for change and more a wayof creating space to step back from fee-for-service volume imperativesand of freeing time for practicewide reengineering. Rather than mo-tivating individual change, payment reform appeared to be relatedto the practice’s quotient of “adaptive reserves” available for changes,echoing recent lessons learned about the primacy of payment reform(Miller et al. 2010).

Given our repeated finding that professional staff lacked a detailedknowledge of, and expressed indifference to, individual incentive for-mulas, policymakers and payers should concentrate more on ways inwhich reformed payment can provide additional support and space forpracticewide transformation and less on individual staff members’ finan-cial incentives. It also raises questions as to whether new primary caremodels without payment changes will be able to make transformationalchanges; and whether those reforms that are in place in many PCMHdemonstrations across the country will have sufficient support to buildmore effective and sustainable primary care (ACP 2006) or whether, asothers have argued, it will be too little too late (Hoff 2010). The creationof several large multipayer primary care transformation initiatives at the


state and federal levels linked to robust payment reform will directlytest and refine these concepts on a large scale, providing valuable lessonsover the coming few years.

A third lesson is that challenges in effectively using informationtechnology loomed large at each site. Computers and data were crit-ical factors and frustrations for both reengineering clinical encounterwork flow and carrying out proactive population management. Effortsto redeploy staff to support more efficient clinical documentation usingteamlets, as well as efforts to integrate and work with fragmented datafrom hospitalizations and emergency visits, were recurring observations.We saw repeated examples of how suboptimal IT work-flow designand the lack of interoperability frustrated staff’s transformation efforts.Creative work-arounds could often partially overcome these constraints,but rapid and systemic improvements were frustrated by the inabilityto quickly customize IT solutions. The next generation of EHRs andthe infrastructure for data exchange will need to better support spe-cific medical home needs in order for primary care transformation toflourish.

Finally, although space and the preservation of anonymity precludea more detailed description of the staff energies that we observed un-leashed, there were clearly noteworthy changes occurring. These in-cluded the nurse practitioner who created a brand new role of liaisonhospitalist for the outpatient practice (despite still spending most ofher time in the inpatient setting), the uniquely LEAN-knowledgeableleader of one practice, the more traditional physician practice owner whomade remarkable changes in his ordering practices, and the front-deskstaff who deftly improved bill-filing work flows (demonstrating whycompleted forms were difficult to find in the current system). Instead ofstereotypically beleaguered physicians and other staff simply trying toget though each day, complaining bitterly about dysfunction in primarycare, we witnessed a different dynamic and resulting set of activitiesaround the daily work of improvement. The challenge of weaving to-gether and sustaining these activities on a local practice level, in additionto an even greater challenge of coordinating efforts to overcome largersystem dysfunction, looms large. The viability, sustainability, and gen-eralizability of these internal transformations and the renewed joy inwork that we witnessed are contingent on external reforms that takeinto account the staff concerns that we identified (Miller et al. 2010;Nutting et al. 2009, 2011).


Limitations and Strengths

Our qualitative inquiry was part of a larger evaluation plan with designaspects beyond our control, some of which may pose limitations to ourfindings. Although control practices will be included in the quantitativeevaluation, this qualitative evaluation plan did not have the resourcesto employ a sampling strategy that would have allowed us to comparethese atypical, highly motivated practices to control practices. Thus, wecould compare only the practices with one another and draw general-izations based on their experiences. Owing to individual confidentialityagreements, we also could not identify each attributed quotation.

Our evaluations relied heavily on the subjective staff impressions, withobvious biases and recall limitations. We also had no baseline qualitativedata, owing to the naturalistic timing of the demonstration projectand the evaluation plan that followed. Our retrospective interviewingstrategies attempted to reconstruct this chronology of change while on-site at the site visits, but we acknowledge the loss of longitudinal datacaptured in real time. Finally, a one-day site visit can hardly do justiceto the enormous complexities of any primary care practice, especiallyone undergoing significant change efforts. We tried to maximize ourlimited time by using several evaluation team members to conduct thevisits and following a four-step process of interviewing and observationsthat would enhance our efforts to triangulate the data.

We also made time for systematic group debriefings to “debug”and internally critique our varying insights and conclusion. The var-ied ages and professions among our team members (which included astudent and nurse) could have either helped elicit the trust necessary forhonest conversation with providers or inhibited other staff from candidlysharing experiences and concerns.

Conclusions

As the PCMH movement grows and gains experience, we must learnas much as possible (and in as many ways as possible) from the PCMHexperiments currently under way. Given the emerging consensus thatsuch delivery changes are needed, understanding how practices are im-plementing change may be as, or even more, important than simplydemonstrating improved short-term outcomes—the primary goal of theinitial wave of projects. Examining on-the-ground specifics of how five


pioneering pilots were implementing a model tied to payment reformprovided eight linked insights into defining and measuring medicalhome transformation, as well as the primacy of payment reform for cre-ating a space and structure for practices to work on rapidly reconfiguringthemselves.

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Acknowledgments: We want to acknowledge the staff of the remarkable prac-tices we visited, who generously and honestly shared their time, insights, andexperiences with us. We also thank Lydia Flier for her editorial assistance. Ourstudy was funded by the Commonwealth Fund. The funding source had no in-volvement in the design or conduct of the study, data management or analysis,or authorization for submission.

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