Is it just me, or is the PCMH complete crap

[HooliganSnail]

I've looked up tons of definitions of a PCMH, and mostly you find a lot of confusing administration speak that makes the concept even more hazy. It seems that if you ask five "experts", you get five different answers, and none of them seem to know what a PCMH actually is.

This is my take:

A PCMH is a administrators dream that incorporates tons of extra staff like "outpatient care coordinators" to ensure that physicians or other "providers" are meeting previously established quality metrics and ensure that all visits are 12 minutes. It is a product of corporate medicine, and we are throwing tons of resources into developing these "homes", but they don't actually seem to help any of the patients.

Am I wrong?

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[DrMidlife]

Group Health in Seattle spent about 60 years producing a functioning PCMH model. Functioning, not perfect. Most orgs that are trying to adopt the model are failing for the usual billion reasons.

 

[deleted87716]

http://www.pcpcc.org/content/results-evidence

 

[VA Hopeful Dr]

http://www.pcpcc.org/content/results-evidence

I'll try and find it, but wasn't there a fairly recent study that didn't really show any positive outcomes from the PCMH model?

Edit: Found it... http://jama.jamanetwork.com/article.aspx?articleid=1832540

 

[deleted87716]

I'll try and find it, but wasn't there a fairly recent study that didn't really show any positive outcomes from the PCMH model?

Edit: Found it... http://jama.jamanetwork.com/article.aspx?articleid=1832540

The article was written about a single 3-year pilot program in Pennsylvania, and there were some positive outcomes, just far less than they'd hoped for. There are so many variables involved that I'd be hesitant to draw any conclusions from this example alone. There are plenty of other examples (see my link in the previous post) that show different results.

I'd be curious as to why the doctors each got $92,000 bonuses if they didn't do jack. Maybe they should've been paid based on performance.

Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92 000 per primary care physician during the 3-year intervention.

 

[VA Hopeful Dr]

The article was written about a single 3-year pilot program in Pennsylvania, and there were some positive outcomes, just far less than they'd hoped for. There are so many variables involved that I'd be hesitant to draw any conclusions from this example alone. There are plenty of other examples (see my link in the previous post) that show different results.

I'd be curious as to why the doctors each got $92,000 bonuses if they didn't do jack. Maybe they should've been paid based on performance.

Well that's easy, you get bonuses for PCMH by following the rules set forth by NCQA. Has nothing to do with quality, at least from that standpoint.

I guess my real beef is that while lots of the PCMH stuff should improve outcomes, the implementation has been poorly done. Most places, my current job included, just do it for the reimbursement bonus. It doesn't actually change much about the practice to hit all the goals to get PCMH certified.

 

[deleted87716]

Well that's easy, you get bonuses for PCMH by following the rules set forth by NCQA.

Only if payers agree to them. There is nothing about getting certified as a PCMH that automatically increases income.

Shared savings and/or a performance-based bonus makes more sense, IMO (and it's the way we're doing it). If you just give people more money, they don't have much incentive to do anything differently. NCQA certification is only the first step. You have to do something with it. This could explain the poor results in the JAMA article.

Here's what others have to say:

http://www.newswise.com/articles/ph...home-successes-ignored-by-outdated-rand-study

 

[VA Hopeful Dr]

Only if payers agree to them. There is nothing about getting certified as a PCMH that automatically increases income.

Shared savings and/or a performance-based bonus makes more sense, IMO (and it's the way we're doing it). If you just give people more money, they don't have much incentive to do anything differently. NCQA certification is only the first step. You have to do something with it. This could explain the poor results in the JAMA article.

Here's what others have to say:

http://www.newswise.com/articles/ph...home-successes-ignored-by-outdated-rand-study

Agreed, and that does seem to be where the more progressive hospitals in my area are heading.

 

[AtlasMD]

Yes, I personally think the patient centered medical home is equivalent to the emperors new clothes.

The transformed project even showed a 30% increase burnout physicians transitioning to the primary care medical home.

Probably not good when our national Society is recommending a "solution" that burns out physicians 30% quicker.

 

[HooliganSnail]

As a medical student, the PCMH feels like a death trap. Keep in mind that I will be part of a generation of physicians who will never have practiced privatly, and have enormous debt. We will get caught up in the tidal wave of salaried physican spots in these massive ACOs without ever having the experience to know what income can be generated in private practice. That does not put us in a strong bargaining position. Corporate med will say "Hey this is what we will pay you, and we need you to see 45 patients a day". If the PCMH administrator wants 12 min visits, then 10, then 8, I won't be able to push back. Many will run from primary care as fast as their legs can carry them.

The only bright light on the horizon is direct pay. Maybe that is the solution that this nation is starving for.

 

[deleted87716]

Corporate med will say "Hey this is what we will pay you, and we need you to see 45 patients a day".

This has nothing to do with the PCMH.

It sounds like you have concerns about being employed by a large health system, as well you should. Direct-pay isn't the only other option, however. Join a medium- to large-sized private practice and you can have the best of both worlds.

 

[deleted87716]

The transformed project even showed a 30% increase burnout physicians transitioning to the primary care medical home.

The same study that suggested an increased rate of burnout during practice transformation also showed positive outcomes. Personally, I suspect that the "burnout" is transient, and associated with the transformation process itself. Once things have stabilized and a practice is chugging along, I suspect this will improve.

My personal experience with PCMH implementation (as well as EHR implementation previously) certainly mirrors this.

Study Finds Higher Morale, Job Satisfaction Associated With PCMH Model
http://www.aafp.org/news/practice-professional-issues/20120314pcmhmorale.html

 

[AtlasMD]

Blue dog, I love ya, but 'transient burnout' is going in the record books.

And as to high morale, our profession is overflowing with morale...thanks the emperors new clothes.

 

[deleted87716]

Blue dog, I love ya, but 'transient burnout' is going in the record books.

And as to high morale, our profession is overflowing with morale...thanks the emperors new clothes.

Maybe I just know a lot of happy FPs.

As for the "transient burnout" thing, the issue is assuming that what you're measuring is actually "burnout" (which is a long-term phenomenon) rather than situational stress related to transient change. For example, when we implemented EHR in 2009, I had to work my ass off to get charts abstracted, adapt my workflow, etc. It sucked. But I got through it. And, after 3-6 months, things settled back into a routine, much as before...but with the added benefits afforded by an EHR compared to paper charts. In short, it was worth it.

If you'd polled me during that initial 3-6 month period, however, I'm sure I'd probably have been considered a candidate for burnout.

 

[HooliganSnail]

My personal experience with PCMH implementation (as well as EHR implementation previously) certainly mirrors this


Blue Dog,

What are your personal experiences with PCMH and how is it different from your previous practice? I still don't really understand the whole thing, maybe that is why I am skeptical of the PCMH.[/quote]

 

[deleted87716]

What are your personal experiences with PCMH and how is it different from your previous practice?

Well, we're still in the process of getting certified. The biggest change has been getting our staff more involved in patient care and follow-up. A lot of preventive care-related issues (e.g., vaccinations, screenings such as Paps, mammograms, and colonoscopies) as well as care management (chronic disease management, transitions of care, etc.) can be delegated to staff once the staff has been appropriately trained. This frees the physicians focus on actual patient care. We're doing more with patients outside the face-to-face office visit, as well. Some patients are on care plans in order to improve compliance, diabetic control, etc., which may involve regular phone contact by staff or even scheduled nurse visits in the office. We've already seen some real success with this. We didn't have to hire any additional staff to do this, and our staff has found the increased responsibility to be very empowering. We've also had to standardize a lot of our documentation in order to facilitate data-mining in our EMR. The ability to produce reports in order to show outcomes and quality measures is critical when you're getting paid based in part on how well you're taking care of patients.

Time will tell how this all translates into outcomes, but so far, so good.