Is PCMH going to be implemented everywhere for Family Medicine?

Discussion in 'Family Medicine' started by KnuxNole, Jul 28, 2015.

  1. KnuxNole

    KnuxNole Sweets Addict
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    I feel like the only person in Family Medicine who hates this PCMH ****. Everyone seems to praise it and shove it down my throat... but it's making me hate my speciality badly. It's actually pushing me away from outpatient medicine altogether, which makes me a bit sad, considering the fact that I like seeing patients in the clinic setting.

    Am I a bad FM physician if I don't love this PCMH thingy with all my heart? It really has severely worsened my liking of FM, and that thought to me is scaring me...
     
  2. cabinbuilder

    cabinbuilder Urgent Care Physician
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    Please tell us what PCMH is? I have no idea. Thx.
     
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  3. DrMidlife

    DrMidlife has an opinion
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    well there's the IDEA of the patient-centered medical home, where you have a family med (or other primary care) doc refereeing the overall care of a patient, and you maybe avoid the fragmentation of specialist care, and maybe help some patients not get lost in the system, and maybe reduce costs such as when the primary care doc already ordered a head CT and the endocrinologist wants his own head CT, and maybe there are some EMR/EHR tricks to improve communication and quality, and maybe someday this will result in a primary care system that looks like <insert foreign system here, but it's never a country that realistically compares to the US, like Brazil Russia India or China>

    and then there's the IMPLEMENTATION of the patient-centered medical home, where execs looking for revenue push it down the throats of all the providers and office staff without asking questions first, and nobody wants to pay for the unreimbursed work, and insurers just assume it's a new name for the requirement to get a referral before seeing a specialist. Etc.

    KnuxNole I'd be interested to know where the breakdowns are for you. Good topic.
     
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  4. Blue Dog

    Blue Dog Fides et ratio.
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  5. cabinbuilder

    cabinbuilder Urgent Care Physician
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    Thanks, I remember now that I heard about it at OMED this past year. I didn't remember since I don't do clinical FP anymore.
     
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  6. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    While I was never a huge fan, PCMH didn't seem an awful idea to me either in residency or when I did regular FM.

    Now meaningful use is a whole other story....
     
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  7. Blue Dog

    Blue Dog Fides et ratio.
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    Ditto that.
     
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  8. Doctor4Life1769

    Doctor4Life1769 **tr0llin, ridin dirty**
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    Seems like everyone is complaining about meaningful use, including specialists.

    It sounds like a pain in the ass personally.
     
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  9. KnuxNole

    KnuxNole Sweets Addict
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    Yes, meaningless use makes me roll my eyes so hard.

    The general gripe I have about it is that it seems to be about making things "cost effective" and better for the patient when in reality it adds unnecessary headaches. Also, whenever I read anything about it or hear a talk about it...it sounds so pretentious I sorta cringe. Like when they talk about "physicians leading a team" or "making waves on coordinating care". Maybe I'm a naive resident, but you don't need to even know what PCMH stands for to know how to manage a clinic with your MAs and appointment staff. I would prefer not to simply oversee a bunch of NPs/PAs. And working with consultants can be easy with open communication. My notes get sent to their office and vice versa + I always be proactive and dig through the EMR to see what XXX specialist has to say, instead of simply waiting for a faxed note. Also, I sometimes send consults outside our hospital if I know the patient will be better off with a good physician I like and trust, which apparently goes against what they require. There's another aspect that irritates me, but I can't think of it off of the top of my head....

    All I wanted out of outpatient medicine was to see patients, but all of this shoved down my throat is giving me internal bleeding. It is making me want to solely be a hospitalist(my original plan was to be a hospitalist, then do outpatient medicine till retirement).

    Also, I don't think e-mail or god forbid texting would make "communicating with patients" easier. At least in my opinion. Hell, I don't think half the patients I see write e-mails.
     
    #9 KnuxNole, Aug 4, 2015
    Last edited: Aug 4, 2015
  10. Blue Dog

    Blue Dog Fides et ratio.
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    [​IMG]
     
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  11. DrMidlife

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    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.
     
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  12. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    The problem with trying to do this sort of thing under the current FFS model is how do you pay for it? Insurance doesn't pay you, generally speaking, for coordinating care. You get paid when the patient is sitting in front of you. If you're efficient with a good payer mix, you can make enough money to hire people to do the coordination of care. However that good payer mix isn't the problem.
     
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  13. DrMidlife

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    I'm still ramping up on the vocabulary but it's my understanding that Humana capitates payments on a closed census. So it's not fee for service.

    Now I get it.
     
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  14. Doctor4Life1769

    Doctor4Life1769 **tr0llin, ridin dirty**
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    Humana allocates a set amount per patient.
    Anytime a humana patient is admitted to the hospital, you lose that amount of money. It's like a bundled payment from what I understand. Keep 'em out of the hospital and you keep the green by managing all their complex issues on an outpt basis
     
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