The Evisceration

of the

Patient-Centered Medical Home

 

In 2007, the American Osteopathic Association along with the  American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, released the Joint Principles of the Patient-Centered Medical Home (PCMH).

Central to the concept were the following principles:

·                    Personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care."

·                    Physician directed medical practice: "the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients."

·                    Whole person orientation: "the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals."

This unproven concept has certainly captured the imagination of insurers and legislators alike with large amounts of time, money and resources being poured into demonstration projects around the country.  It sounds good.  I seriously doubt it will save a significant amount of money.  Here’s why.

Unproven Tenants

The National Committee for Quality Assurance (NCQA) is a driving force behind the PCMH model, creating standards and guidelines to facilitate partnerships between individual patients and their personal physicians. Blue Cross Blue Shield of Michigan (BCBSM) and others have also embraced the PCMH concept as a way to lower costs.  But there is absolutely no data, just theory, that the following principles have any merit at all:

  • ·                           Patient engagement as well as a team approach for managing their health will deliver higher-quality, lower-cost care.
  • ·                           Patients are more likely to receive the care they need in the appropriate setting, and decrease their use of the ER for non-emergency conditions.
  • ·                           By proactively “managing” chronic conditions, Primary care physicians (PCPs) may prevent hospitalizations.

    Meanwhile, Back at the Farm…

    At PrimeCare of Novi (@primecarenovi), we have embraced the basic concepts of dedicated patient-centered care for many, many years.  The only good thing to come out of our certification is that we do, indeed, receive a 10% upcharge for having received the PCMH designation so we can get paid a little more for what we have done for a long, long time. It does not come close to covering the overhead.

    In 2009 we expanded our professional staff to employ a Behavioral Therapist to help with many of the emotional and psychological issues that afflict our patients.  These therapists are highly-trained specialists and are much better equipped than I to spend the time and develop the treatment plans that would help treat these patients.  Everyone thought this was a great idea.  BlueCare Network, one of our HMO’s really endorsed the idea as a “practical application” of the PCMH principles of care.  “Good job” they said.  They just would not pay for the care we provided.  Exit the therapist.

    Which PCPs are Really Involved?

    It flabbergasts me that it is possible to be designated as a PCMH and not have the PCPs involved as Attending Physicians.  When a patient is admitted to the hospital there is one physician in charge of the case – the attending physician.  Wouldn’t you expect that a PCMH concept would emphasize the necessity of having the PCP involved in some of the most highly significant medical treatment that the patient will receive in a given year?  You might think so.  You’d be wrong.  The process has become so politically correct -- we must not offend anyone—that most PCMH-designated practices regularly ship their inpatient care off to hospitalists who are more often that not totally disconnected form the PCP practice.  There is no continuity of care.  It’s a complete myth, an illusion, and one allowed because docs have given up the standard of actually “caring” for a patient in lieu of having EMR registries to “track” disease states.  What a joke!

    At our hospital we have meetings galore about the lack of information flowing between the hospitalists and their PCP’s.  The “Meaningful Use” (MU) criteria mandated a “reconciliation” processes when someone is discharged from the hospital, something we have been doing at PrimeCare of Novi (@Primecarenovi) for years, so that the medications that the patient was discharged on are the correct medications the PCP wants continued. 

    I have an idea: — maybe the practice shouldn’t be considered a Medical Home until they do the things that actually make it a “home.”  Oops, I guess that wasn’t very politically correct. 

    Regulated to Death?

    It’s a daily article that suggests that organized teams within the doctor’s office are needed to track the diseases, involve the patients, follow-up on every loose end from meds not filled to colonoscopies ordered and not done.  One of the surest way to the in-patient side of the psych ward is to get yourself in a situation where you believe you have to do something, and can’t.  PCPs can’t be expected to control obesity, address the psychosocial ills of our society, provide the highest quality care to all comers at a minimal cost.  It can’t be done.   It won’t be done. And when PCP’s realize that they have been hoodwinked by a 10% upcharge into taking on a Herculean task with no possibility of success, they will bail.  I expect many of my colleagues will do one of two things – sell to the hospital and become 9-5 employees, or declare themselves to no longer be PCPs, but Urgent Care centers, which are neither expected, not equipped to follow-up or track a darn thing.  It’s as predictable as the fact that Spring and the voice of Ernie Harwell’s turtle will soon be upon us.  Ernie used to say that the great thing about being on the earth 80-some years was that you had seen a lot of things come and a lot of things go.  And when this eviscerated concept of a PCMH finally dies, perhaps docs can once again resurrect the concepts that built medicine into the venerable profession it  needs to be, and once again do what professionals has always done:   Whatever it takes to get the job done, fairly and equitably, with the attitude of true servant-leaders.  

    TWS

    Novi - 3/19/13