Medical practices and physician trade groups have struggled for years with the concept of a patient-centered medical home. Most of their attempts haven't stuck, especially if they're not working with a decent-sized grant. And I'm not surprised.
I'd argue that until we answer some key questions and get firm support from health plans, the PCMH concept will devolve into a mess which won't solve the health systems' real problems.
It's not that physicians aren't trying to make the model work. Many physicians' groups, including The American College of Physicians, American Academy of Pediatrics and others, have come out with PCMH guidelines and training material designed to help physicians get started.
But books and online training—even in-person seminars—won't cut it on their own. There's actually a tremendous amount of effort and cost involved, including building a new team-based approach to care, appropriately training staff to provide coordinated care and buying health technology to support the practices.
So here's some questions practices should answer before they can go into PCMH mode:
- Do you have the resources? Unless you have a large cash reserve to run through on this, PCMHs can't dive in unless health plan reimbursement models pay for care that falls outside of the standard face-to-face encounter.
- Do you have a clear definition of what your PCMH will be? Any time there is a major change in how an organization practices medicine, there will be some doubts, insecurities and fear. Before you take major steps, it's important to develop a consensus as to how your medical home will run. After all, while trade groups, private organizations and the federal government are attempting to standardize the outline, there's still no completely fleshed-out external opinion.
- Can your infrastructure support a PCMH? Remember when you bought that EMR system? If you want to start a PCMH, now's the time to be glad you have it. Tracking patients on paper may be possible, but certainly not the most efficient way to get the job done. And if you want to report results to outside parties, again, your EMR will be your friend.
- What about concierge or direct primary care? If you're willing to give what up PCMH requires of you, including some form of 24-hour access to your patients, and you want more time with your patients, perhaps you'd rather be a direct primary care or concierge practice. Or, if you're up for more radical change, you can go with a direct primary care model—one in which you accept no form of insurance but instead collect a monthly flat fee for the patient ($40 to $100 per month is typical) for unlimited medical care.
- Is the evidence that PCMHs work strong enough? Because the PCMH concept is evolving and PCMH settings vary widely, researchers have found wildly different results in different PCMH settings. Of course, you can go with your gut and give the medical home model a chance to evolve in your organization. And you may get a boost from the NCQA's new 2014 PCMH standards.
The bottom line seems to be that PCMHs are best implemented as research projects, and pilot tests in cooperation with payers. Trying to turn the medical home model into a platform for rapid improvement in satisfaction or patient outcomes doesn't seem to be in the cards for many who get involved. So, by all means go with a PCMH model if it appeals to you, but keep your expectations low.