PCMH and retainer fee medicine are primary care solutions

For years now we’ve been hearing about the trials and tribulations that have evolved in the practice of primary care medicine.

However, the discussion has intensified in recent months with passage of national health reform. Recent publications highlight the problems. A paper in the New England Journal of Medicine by Dr. Richard Baron entitled, What Keeps Us So Busy in Primary Care? discusses the time spent by primary care doctors on non-visit related work, which according to his findings, interrupts us 43 times daily.

Health insurance reimbursement to physicians is “fee for service,” thus leaving all of this work uncompensated. Moreover, health insurance pays better for procedures than it does for talking to patients. These factors have contributed to perverse incentives: “see more patients, run more tests.”

With current relative shortages of primary care physicians, and the anticipation of more patients entering the health system, attracting new physicians to pursue a career in primary care is seen as critically important. However, medical students hesitate to choose it as a career because of its difficult lifestyle, lower remuneration, and the current practice environment. Recently, I read that HHS Secretary Kathleen Sebelius announced the release of $250 million in new funding to strengthen the primary care workforce. Of this, $168 million is set aside for training more than 500 new primary care physicians by 2015. That’s good news, but who is going to want to pursue this training if the value placed on our time remains so low, and the practice pace remains as hectic as it is today?

What is the answer? There are several current responses to the primary care crisis. On the one hand, the advent of retail clinics and retainer fee medical practices, and on the other hand, the Patient Centered Medical Home model, which has established itself with increasing legitimacy as the best solution. The May issue of Health Affairs was dedicated to “Reinventing Primary Care.” For those of you who have not heard of it, the “Patient Centered Medical Home” (PCMH) is a model of primary care that reorganizes the care team in a way that gets non-physicians more involved, supports patient “activation” toward improved self-care, and uses electronic systems—electronic health records and patient portals—to better manage populations of patients, particularly those with chronic illness. In many ways the Patient Centered Medical Home might really be called the Computer-Centered Medical Home.

The PCMH addresses the problem of access to primary care and is particularly appealing as a solution within certain segments of the insured population, namely, Medicaid and Medicare. Physicians have increasingly dropped Medicaid because of its very low reimbursement rates. This has made access to care, despite insurance coverage, very difficult. A similar problem may soon exist within the Medicare population, with physicians dropping or capping Medicare patients, if an acceptable solution is not reached with respect to the SGR and Medicare’s payments to physicians drops further.

Intrinsic to the PCMH is the concept that primary care should be reimbursed differently. Under this model payment is both fee-for-service and additionally capitated per patient member within the practice. Results of implementation of the PCMH have been published from Group Health Cooperative in Washington and also recently from Medicare’s pilots projects. The Group Health results look promising, showing overall cost savings, related to decreased inpatient and emergency room use. However, reports from the large TransforMED pilot, published in the Annals of Family Medicine, are less promising. “Working feverishly, the 36 participating family practices registered only modest improvements in quality-of-care measures but backslid in terms of how patients rated them.” The authors of the summary conceded that medical home transformation “requires tremendous effort and motivation,” and that most practices would need outside help, as well as adequate compensation, to make the switch.”

Along with the PCMH, retainer fee medicine has appeared in many areas of the United States. Similar to the PCMH, retainer fee medicine, also known as “concierge medicine,” provides extra funding to a medical practice in a capitated manner with a per patient annual fee. The difference is that in the PCMH, the hope is that insurers will provide the additional capitated funding. Another key difference is that PCMH designated practices must prove that they deliver certain elements of care to their patients. In fact, to become certified a practice needs to achieve a long and complex set of criteria. The model has been criticized as being “out of reach” for many small practices, who simply cannot afford the additional layer of clinic administration needed to complete the check list.

In contrast to the PCMH standardization, among retainer fee practices there is significant variability in the type of care delivered, the annual fee charged, and the practice’s adoption of electronic systems and quality reporting. This type of practice typically emphasizes a more “Marcus Welby” approach, with emphasis placed on personal communication and the traditional doctor-patient relationship. Whereas PCMH practices emphasize care teams with more participation of non-physician members, and may in fact increase the number of patients cared for by each physician, retainer fee practices typically guarantee that they will care for fewer patients per doctor.

As I see it both the PCMH and retainer fee medicine are reasonable solutions to current short-comings. What’s wrong with a “Patient-Sponsored Medical Home” practice, structured as a hybrid of these two primary care models, with built in systems to ensure quality, but also structured with the promise of a smaller patient panel for those want a more traditional doctor-patient relationship ? Can the Medical Home have it’s cake and eat it too? Or, will it fail to support the personal aspects of the doctor-patient relationship, the value of which is more difficult to measure with quality metrics and clinical outcomes?

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • KP Internist

    Who says that primary care should be in small group practice? This PCMH model for primary shouldn’t be implemented in such a setting. You need to have a critical mass of patients to make the efficiency in such a system worthwhile. System implementation and maintenance is too high to see cost savings when you operate in solo. Imagine having a a powerful computer and not having it connected to the net. It is useless as a tool. The magic happens when you have large networks of doctors, hospitals, labs and pharmacies all connected and sharing infomation and working together. All primary care doctors should be in a large group to make such an effort worthwhile. The days of the small practice provider is over in this age of technology.

    • http://drkeegan.blogspot.com/ Keegan Duchicela

      But that was the point of defining, standardizing, and coming up with benchmarks for the PCMH.

      Kaiser is already set up to implement aspects of the PCMH. The have enough PCPs. They have nutritionists. They have diabetes educators. And technology connects them all.

      But there existed a need to bring that model to the masses, so to speak. Please correct me if I’m wrong, but I was under the assumption that most physicians are still practicing in small group or solo settings. In many parts of the country, it is impossible to consolidate simply because there aren’t enough physicians to reach critical mass. So the push for the PCMH will hopefully provide a framework that all those small practices can adopt. It’ll be difficult to implement, yes. Will it be as efficient as Kaiser or the other large foundations. No. There’s not the expectation that it can equal them in terms of efficiencies.

      Along the line of discussing cost savings. I really hesitate to tout “saving money” as the saving grace for PCMH and for PCPs in general. First and foremost, I want to make my patient’s life better. I want them to breathe well, walk well, have a clear mind, and be educated about their body. I want to them to live long. And that takes money. It’ll be expensive. A smoker/diabetic who passes away at 50 will use less dollars over their lifespan than a healthy person who dies at 80. We’re not saving money by extending someone’s life. As someone who wants to live long and happy until 80… that’s fine by me.

      • KP Internist

        PCMH model is much harder to make effective than just installing it. It’s proper implementation has to be done top down and not bottow up. This model can only work if it operates in some larger system that can support it. There are many small rural communities that start out as a IPA and then join together is a more loosely knit Permanente-like group. Yes, there is more shared decision making and loss of individual freedom by each provider;but, the tradeoff is better system support, rate negotiation and greater capital resources. My point is that trying to sell PCMH to a small group practice is like trying to sell an ipad to my grandmother. Sure, it nice and sounds good. But, she won’t use it. Yes, when we talk about cost savings. It should be more dollars per quality years adjusted. But, really the PCMH stuff is pretty cheap. It just seeks to increase efficiency at zero cost. Most importantly, it should increase access and patient self management.

    • jsmith

      I don’t want to lower my costs. I want to increase my revenue. Lowering cost is doing the insurers’ bidding. Like a lot of PCPs, I’m sick and tired of being their serf.

      • KP Internist

        JSmith, your sentiments represents the problem with the current health care system. Everyone is out to screw the other side.

        KP is just trying to screw the competition. We are all on the same side. Makes it easy to work together to improve efficiencies that way.

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      KP Internist. Would like to hear more about your thoughts. Send me a message via Lotus Notes – Davis X Liu.

      Davis Liu, MD

  • rwatkins

    At least as defined by the AAFP, the PCMH is a randomly assembled collection of 1980s-era motivational jargon (“change management,” “qualitiy improvement,” “shared vision,” “regulatory compliance,” “mindful communication” and on and on) that has no proven relationship to improved patient health. The results are irrelevant, as long as you do the administrative and bureaucratic chores.

  • http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD

    KP Internist, There you go again, everything must be like KP on a large scale. Give me a break. Gordon Moore has research supporting the efficiencies and patient satisfaction of small practices, including solo. The internet makes the world flat. Why can’t you acknowledge that? Furthermore, small group and solo docs are not trying to bury KP; why do you continue to bury small group and solo docs? There are a lot of docs who don’t want to be an employee but would rather preserve their autonomy. Innovation usually does not come from big, it comes from small, grassroots efforts. There’s room for both of us. But, you have to admit, as Seth Godin says, “small is the new big”.

    • r watkins

      Well said. I’ve worked in both situations: salaried in a large multi-specialty group that also functionned as an insurer. amd in a small, private practice. I definitely prefer the second situation, both in terms of working conditions and care that I am able to provide. However, I would never continually denigrate other options, the way KP Internist does.

    • KP Internist

      Bruce, it is not personal. Small is not efficient when your are talking about what patients and the government expect us to be able to do. How in the world will you expect a small solo practioner to absorb the costs of a EMR, HIPPA compliant messaging, mandatory reporting, and managing registries? Small is not the new or will it ever be big. I don’t remember the last time I went into a neighborhood hardware store. It doesn’t have the prices, selection and services I have come to expect from a big box store. So, I don’t go there.

  • http://www.drdialogue.com Juliet Mavromatis, MD

    Interesting discussion. I too have been employed by a large multispecialty group for 12 years, and now am in solo practice. With respect to the PCMH, I think that small practices and concierge doctors can learn from some of its key concepts–using IT proactively to better manage and monitor those with chronic illness, using systems that help engage patients in more effective self-care and the concept that physicians should hold themselves accountable for providing high quality care as defined by specified metrics. With meaningful use small private offices will hopefully become connected to their main referral centers for subspecialty care, radiology and inpatient care for improved care coordination. The care team may look very different in a solo practice versus a group practice, but that does not mean that the described features of a medical home cannot be achieved in both practice settings. This being said, the administrative costs of monitoring and reporting back medical home criteria to NCQA or payers may be daunting for a small practice. This is where retainer fees or alternative fee structures come in to play in small practices. Patients who invest in such a practice model may buy more one on one time with their physician, as opposed to being one of 3500 patients assigned to a care team in a large group practice. We can all learn from one another, but one common thread is the need for payment reform in primary care.

  • http://www.brucehopperjrmd.com Bruce Hopper Jr MD

    KP Internist, Who said this is personal? I welcome a healthy debate! I just think you a flat out wrong; we think differently, that’s all. But I do have a question for you: if your model is so great, why aren’t med students flocking into primary care at KP? Don’t sell grandmothers’ short, many I know use facebook, ipads, and internet to connect with their grandchildren. I love my neighborhood hardware store and so does everyone in my urban neighborhood. Great selection, if they don’t have what you need (which rarely happens) they tell you where to get it. Phenomenal PERSONALIZED service. When I go into Home Depot or Lowes, good luck if I can find a salesperson, and I frequently walk out empty-handed. My low-overhead practice and HelloHealth electronic platform have everything you mentioned about EMR, and they continue to listen to doctors on the platform and add features each month. Please, don’t get defensive because we don’t share the same opinions. I don’t take it personally… : )

  • http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD

    Dr. Liu,

    I read your blog and respect your opinions. I am in Philadelphia where you received your Wharton MBA.

    I am always fascinated with the MBA philosophy and macro approach. In reviving primary care, however, I believe this approach will always fail because the incentives of primary care will never align with 3rd party incentives. The only way I see primary care making a comeback is to, first and foremost, attract medical students. They are interested. I currently have a Temple medical student arranging an elective with me, and, according to him, there are several others awaiting his experience.

    Sparking this renewed interest, in my opinion, will only happen at the bottom, grassroots level.

    Combining the low-overhead ideal medical medical model with technology (I use HelloHealth), I believe I can see a panel of 1000 patients who pay me a monthly membership fee of $35 and a fee schedule based on $240/hour whenever they see me face-to-face.

    This model is scalable and can, indeed, fit the needs of our country.

    According to my calculations (based on WolframAlpha database) there are 730,801 physicians in US = 2.54 physicians per 1000 people. If primary care became appealing again and 50% of MDs went into primary care, then we can indeed meet the needs of our 300 million population.

    It can be done. But NOT from a “top-down” approach (despite KP Internist and his brethren). Not to say that large HMOs should be defunct. This country needs to philosophically get back on track. Small business is the engine that drives the economy. We need to offer better services to this sector and drive down the cost of healthcare. Big corporations and big government will NEVER allow for this to happen. Better quality, lower costs will only happen at the fringes first, through disruptive innovation, before the tipping point…

    Bruce Hopper Jr MD
    - Show quoted text -

  • agm

    As a medical student who has been following the innovation in primary care I can say for sure that the direct-pay model of Qliance, AgileHealthPartners, CarePractice, BruceHopperJr, etc are very attractive… as far as family medicine can be attractive. When I look at their website, look at their office space I am immediately interested. They are more computer, less paper, more patient, less insurance. More importantly those models CAN guarantee an income where paying off my 200,000 in loans won’t be impossible. Can any other primary care model make that promise?

  • Sailorguydoc

    Fascinating discussion. Diversity of big-box and solo is healthy. There is more than one personality of doc, and likewise for patient.
    I’m in a big group. The EHR we use is clearly designed for enhanced coding in the FFS-maximize-reimbursement world. I am quite unhappy with it. It’s ability to enhance care quality is like trying to saw wood with a hammer. It’s just the wrong tool.
    If we could develop database standards, EHR would be more attractive and more interoperable. Standards do allow me to throw out my Sony TV and plug a Panasonic in, if I want, since they both use the same TV signal. Docs get cold feet with prospects of being wedded to a software vendor! Being able to change up a software package and preserve the patient database would put the practice in charge of the tool, as it needs to be.
    A good EHR is the backbone needed for the PCMH — delivering “best practices” results, adaptable to each size practice.
    I appreciate the thoughtful comments of so many participants.