In my past life as an engineer we called this "throwing it over the wall". Big fat decision in the hands of a group that ignores the hard parts and dumps responsibility on people who can only say no by quitting.
JenCare and IORA are a couple examples of medium-ish-sized primary care operations who are hard core serious about PCMH for the things PCMH is supposed to mean. They have the same headaches, but I'd argue they have good support to fix or deal with those headaches. Hard job, regardless.
JenCare and IORA can take PCMH seriously because they have 100% Medicare patients who have to enroll in the program, and because Humana (or another Medicare payor) has signed up to pay for their model. So billing is single payor. (Half the battle right there.) Humana et al are game to try this because JenCare and IORA directly attack readmissions and unnecessary tests and socioeconomic barriers and mental health and pharm. Shuttle buses. Protected walk-in times. Bulk buys of albuterol etc. Support staff to MD ratio is about 5:1, few-to-no mid-levels. Home-baked EMR that only has to care about one org's needs, heavy reporting/measuring/tracking way ahead of the meaningful use deadlines, used at every level of the company. Coordinators cover the major hospitals and do home visits. Strategy meetings for the most difficult patients because they cost the most. A patient can get kicked out for refusing to work with the coordinators, or for going to the ED for a non-emergency repeatedly, etc. Docs don't take jobs at these orgs if they just want to see patients - all the MDs and DOs are senior members of the management team. Some FM but mostly IM+ such as geri, rheum, ID, heme/onc.
(Most of my classmates would quit med school before they'd work like that.)
I get depressed when a program that wants to be this functional and realistic can only work by managing a paid panel (same beef w/DPC). But after rotating at JenCare and seeing what PCMH looks like with low socioeconomic patients, when you remove some of the worst obstacles, and you're not just f***ing around pointlessly, at least I felt some hope. Gotta be happy that small somethings are getting done regardless of the big picture.
Still flummoxed by the sheer enormity of chronic illness mixed with socioeconomic trainwreckage.
Other viewpoints on this are welcome - I want to learn.