The PCMH – Barriers to Full Implementation
Although the PCMH is routinely confirmed as a viable reform strategy, there is still resistance to adoption
By George Martin, MD – Senior Medical Director for Health Integrated
By way of introduction, my name is George Martin, MD. I am the Senior Medical Director for Health Integrated. I have the pleasure of accepting the responsibility and to have tag teamed with Jay Pomerantz, MD on our Health Executive Leadership Blog. As one who has spent the past 15 years managing and consulting on the implementation delivery, coordination and payment for healthcare, I am passionate about healthcare reform and see how an increased focus on primary care and being able to address some of the other challenges facing health plans and other stakeholders in the healthcare community will help to improve outcomes while reducing overall cost. I am excited to be facilitating your communications on these relevant topics.
As was mentioned last week, one of the sessions in the upcoming Health Integrated Fall Executive Leadership Series Event in Chicago on September 22 – 23, will allow detailed discussion concerning the world of reform and the healthcare landscape. Julie Barnes, Director of Health Policy at the Bipartisan Policy Center, will facilitate a healthcare panel. The discussions will include looking at innovative programs such as ACOs and PCMHs. This is a very relevant session given the current state of reform. I encourage your participation. Visit our website for more details.
It has been several months since we have discussed the Patient-Centered Medical Home (PCMH), and as you can imagine, the pilot programs that have been implemented across the country continue to produce positive results. Today, I would like to share some thoughts on the challenges and perceived barriers to implementation beyond the demonstration phase.
When I first heard a presentation of PCMH, I had two thoughts:
- Who had we been centered on
- The medical home did not seem new
Indeed the American Academy of Pediatrics initiated the patient home concept in 1967. Since then, most all of the primary care specialty societies have agreed on, and some have formalized a set of principles for the PCMH concept – including care coordination, reduced patient loads and extended access hours to name a few. These lofty principals assume a trained patient care team that is readily available at the point of care.
So, in gaining more insight to understand the barriers to adoption, it is helpful to remind ourselves that the vast majority of PCPs are not part of large group practices. Most are in groups of 3-4 physicians, or in coverage groups where they share only night call and not office space. Additionally, the demands of declining reimbursement and increasing regulation are creating busy offices with no space to waste. Prior to the current recession, scheduling an appointment with your PCP took significant pre-planning in most markets. The supply of, and subsequent availability of PCPs has been and will continue to be challenging.
We gain additional insight when we layer on top, some collaboratively-designed ‘guidelines’ from the Joint Principles of the Patient-Centered Medical Home established in 2007 by the AAFP, AAP, ACP and the AOA.
- “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.”
The challenge here is that many physicians either have no training and little inclination to accept this role, or they believe that they already operate this way. Without training and direction, there are few if any outcome metrics, no improvement processes and even if they did exist, there would be precious little time for implementation in an already over-worked system. Additionally, the poor reimbursement rates further make many of these goals difficult to achieve without access to outside resources.
- “Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”
How many additional resources would be required for a single physician practice? The coordination by definition would require cross-organization communication and cooperation. This is possible, but needs to be planned and driven. This is the case in Grand Junction where facilities, private and government, cooperatively work for the total community benefit.
- “Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.”
So, just how many hours do we want our personal physicians working? Some ideas within the PCMH have been proven to help – reduce workload, yet increase care. In the demonstration projects, using Group Health as an example, the patient base for each physician was reduced from a national average of over 2300 patients to 1800, while allowing the physician more time with each patient so to migrate from an ‘episodic treatment regimen’ to a more preventive approach[1].
In order to accelerate adoption then, how do we remove the barriers? Here are some ideas:
- Increase the supply of physicians – Normally supply and demand balance each other but the system has become a bit tangled. The ARRA and healthcare legislation has a focus on incentivizing medical students toward primary care as a specialty. Although helpful, this is a longer-term solution
- Provide resources to support the PCMH – Although reimbursement and incentives are a key to this effort, there are infrastructure requirements as well. ARRA has allocated some $36B for EMRs which can be the information al hub for physicians and patients alike. The recent Affordable Care Act needs to move the focus from studying PCMHs to implementing, and allocating the associated resources for more immediate deployment
- Train and retrain the physicians - Medical schools and residencies have, this decade, begun to educate physicians about the need to deliver care to patients as well as to treat disease. But this leaves decades of practicing physicians without the perspective of patient centered care. Retraining is critical
So what’s the answer? In an ideal world and if I were king for a day, I would like to recreate the system starting with a blank slate. Then, after rejoining the real world I would realize that this is not feasible and therefore not likely to happen. This said though, there are many (over 27 multi-stakeholder/multisite to date) PCMHs operating in the US currently that have shown great promise in the accomplishment of their primary objectives – providing better health outcomes while reducing overall cost. Cases in point include Geisinger, Community Care (NC), Southeastern Pennsylvania Project, North Dakota Blue Cross/Blue Shield[2] and Group Health[3] just to name a few. These examples show it can be done, despite many of the barriers that exist. I continue to be encouraged. I have attached several documents that you might find interesting regarding the PCMH.
Thank you for welcoming me into my new role. As always, I appreciate and encourage your thoughts. You can reach me directly at healthexecforum@healthintegrated.com or comment directly in the blog.
Best Regards,
George Martin, MD
Notes:
1. Download: Incremental Cost Estimates for PCMH
2. Download: Medical Home Position Statement
3. Download: PCMH Guidelines by Major Physician Groups
4. Download: Guidelines for PCMH Demonstration Projects
5. Download: Outcomes Research Agenda for PCMH
6. Download: Defining & Measuring PCMH
[1] See Group Health Post: http://blog.healthintegrated.com/?p=244
[2] http://blog.healthintegrated.com/?p=80
[3] http://blog.healthintegrated.com/?p=244 – Group Health Cooperative
