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Off the Hamster Wheel? Qualitative Evaluation of a Payment-Linked Patient-Centered Medical Home (PCMH) Pilot



The Issue

While there is broad agreement on the general concepts defining patient-centered medical homes (PCMHs), little is known about physician practices' on-the-ground experiences. In this Commonwealth Fund–supported study, researchers examined five practices engaged in efforts to become medical homes. All five practices received a risk-adjusted base payment per patient per month to support their efforts.

What the Study Found

  • Practices adopted different approaches, from hiring new staff to focusing on care management to improving workflow.
  • Some practices perceived value in working with external consultants, but two multispecialty group practices preferred to nurture internal culture change, supplemented by reliance on Lean process improvement methodology—a management philosophy that originated in auto manufacturing.
  • All practices used health information technology to reengineer clinical encounters, improve information flow, manage chronic care, and create patient portals. The researchers heard examples of both success and frustration with the technologies.
  • Practices used teams and teamwork in different ways. Notably, one practice with a hierarchical leadership approach stood out for having made the most progress in increasing efficiency and improving care—thus raising the question of whether a top-down approach might have a greater impact than team-based approaches, at least in the short term.
  • There were tensions between going too slow and pushing too hard and fast to make changes. In some cases, nurses and medical assistants felt overloaded with new responsibilities.


This qualitative analysis revealed that medical home transformation means very different things to different practices. For this reason, similar analyses will be important for assessing the future experience of PCMHs, beyond clinical markers and claims data. The new payment model allowed the practices to jump off the "hamster wheel" of fee-for-service payments and gave them the opportunity to improve care.

Publication Details



A. Bitton, G. R. Schwartz, E. E. Stewart et al., "Off the Hamster Wheel? Qualitative Evaluation of a Payment-Linked Patient-Centered Medical Home (PCMH) Pilot," Milbank Quarterly, Sept. 2012 90(3):484–515.