In 2007, multiple primary care organizations (American College of Physicians [ACP], American Academy of Family Physicians [AAFP], American Academy of Pediatrics [AAP], and American Osteopathic Association [AOA)] agreed upon the basic elements of a patient-centered medical home (PCMH). In an effort to promote the adoption of these elements, the National Center for Quality Assurance (NCQA) has, in consultation with the same primary care organizations, established a set of standards for achieving a PCMH, divided into 3 levels of achievement, organized along 9 areas, and comprising 30 discrete elements, 10 of which are mandatory “must passes.” Level I recognition requires meeting 5 of these must pass elements; level II or III recognition requires the applicant meet all 10 of the must pass elements and corresponding prescribed point levels.
It occurred to us that it might be useful to contemplate these standards in light of what the Institute for Healthcare Improvement is now calling the “triple aim” for improving care—managing (reducing) overall costs, ensuring a great patient experience of care, and achieving both process and outcome measures of care quality. The recent national demonstration project of the American Academy of Family Physicians—TransforMED—has shed light on both the apparent obstacles to achieving these goals and standards, as well as the kinds of resources that will be needed to overcome the barriers. We offer, as a stimulus to discussion and perhaps as a guide to empirical investigation, the following matrix in which we portray the NCQA elements along one side and the several kinds of benefits and costs along the other side. Based on our experience as practitioners and investigators, and with some support from existing literature, we suggest that there may be real differences in the relative intensity of both benefits and costs for each of the 30 NCQA elements, and indicate that by showing 1, 2, or 3 pluses in a cell to signify the relative intensities of costs and benefits:
We have chosen to simply add the numbers of pluses in the 3 benefits columns and divide them by the sum of the pluses in the costs columns to derive a crude estimate of the benefit/cost ratio for each of the NCQA elements. There are obvious shortcomings to this—different constituencies would necessarily assign different utilities to each of the elements portrayed across the top, and we have not shown the reader a systematic review that would support our personal assignment of values to each cell. Think of the table ▶ below as more of an illustration or example to communicate a way of thinking about this issue. Nonetheless, it is intriguing that our personal assessment of benefit vs cost ratio bears little relationship to the points that the current NCQA rubric assigns to each of the elements of a PCMH.
Table t1.
| Benefits | Costs | |||||||
| NCQA PCMH Standard | NCQA Pts | Reduce Cost | Care Experience | Quality | Leadership | Team Resources | Capital | Benefit/Cost |
| 1.Access and communication | 9 | ++ | +++ | +++ | ++ | ++ | + | 1.6 |
| 2. Patient tracking | 21 | ++ | ++ | +++ | +++ | ++ | +++ | 0.87 |
| 3. Care management | 20 | ++ | +++ | +++ | +++ | +++ | +++ | 0.89 |
| 4. Patient self-mgmt support | 6 | ++ | +++ | +++ | + | ++ | + | 2.00 |
| 5. Electronic prescribing | 8 | ++ | ++ | +++ | + | + | ++ | 1.75 |
| 6. Test tracking | 13 | + | + | ++ | + | + | ++ | 1.0 |
| 7. Referral tracking | 4 | + | + | ++ | + | + | ++ | 1.0 |
| 8. Performance improvement | 15 | + | +++ | +++ | +++ | +++ | + | 1.0 |
| 9. Advanced electronic comm | 4 | + | ++ | ++ | + | + | ++ | 1.25 |
In creating this table ▶, we imagined “starting from scratch,” and we recognize that the costs, in particular, might be different for some established practices, and would certainly be different for a practice to maintain the elements. We are also cognizant that both the NCQA elements and the table do not explicitly attend to a key finding of the TransforMED project: it’s all about relationships: doctor-patient, doctor-nurse-staff, and practice-community. Practices that are mindful of all of these relationships and that are relatively good at keeping them healthy are more likely to achieve and sustain the technical elements portrayed in the first column. Perhaps the columns that portray the need for leadership and for team investment are a reasonable proxy. In any case, the point of the exercise is to suggest that it may be worth thinking about what kinds of benefits accrue when one adopts each of the standards, what kinds of resources (people, time, and money) are necessary to establish the standards, and how the relative value assigned to each resource expense or benefit would depend upon what constituency is making that judgment. It also suggests that empirical research that takes into account all of these costs, benefits, and stakeholder perspectives would be more helpful than that which only examines a portion of the costs or a portion of the benefits for a single constituency.