Care delivery transformation requires an upfront investment

When I was traveling around the country interviewing for a residency spot in family medicine in the fall of 2008, I was eager to find a patient-centered medical home (PCMH). At every interview, I asked whether the program’s clinic was a certified PCMH or whether it was moving in that direction. “Well, we don’t yet know what that looks like” was the answer that I heard at nearly every destination. This baffled me; what do you mean we “don’t know what it looks like?” The Joint Principles had been released the year before; demonstration projects were in motion. What more did one need to set it up? This was being touted as the future of primary care, and as such, I wanted to be trained in that model. The program I ended up matching with was the one program that provided a different answer.

The University of Utah, in Salt Lake City, had transformed its practice to a model called Care By Design. It is based on 3 main principles: team-based care, appropriate access, and planned care. “We don’t know what the PCMH looks like, but we went ahead with the redesign that our clinics needed to undergo” was the answer I received in my interview.

Granted, I was a bit naïve about how easy it might be to redesign a practice, but I continually wondered what the barriers were to this transformation. How significant of a barrier was inertia – the desire of many practices around the country to continue with business as usual no matter how poorly designed? Was resistance to the PCMH an outgrowth of the gradual movement towards a more physician-oriented health care “system” over the last few decades? Was it merely about money, the fact that PCMH requires an upfront investment that can be difficult to obtain? Was it true that there was not enough information about PCMH design at that time?

I think there are multiple reasons for this resistance, still widely seen nearly 4 years later. First of all is money. The adage that money rules the world is unfortunately true. Care delivery transformation does require upfront investment that many practices don’t have. There has also been a major concern that payers will not provide appropriate compensation for increased time spent by teams caring for patients. Payers seem to be saying they’ll pay us when they see the transformation, and we seem to be saying that we’ll change when we start getting paid appropriately. Fortunately, these concerns are being put to rest and the stalemate is coming to an end. The Affordable Care Act (ACA) has encouraged such payment reform. The VA system and private payers such as WellPoint and United HealthCare have started encouraging such redesign through payment reform and incentives. Many states are adjusting their Medicaid program to emphasize care in a PCMH. More organizations are following. Those not transforming will continue to fall further behind financially as payers continue to evolve.

Another reason behind physician hesitancy is likely change fatigue. Looking back at the last two to three decades reveals constant adjustment in health care payment and structure, from decreased support for government programs to managed care to not-managed-care to some weird thing called the PCMH. Physicians who have practiced through any of this are understandably tired of dealing with these constant changes, which have contributed mightily to burnout and practice inertia. I believe that this seemingly constant change has been the main driver of medicine’s becoming more physician-centric, and subsequently more complicated and less efficient for patients. Why would physicians want to jump on to a new notion that may be gone in a few years when the next panacea of reform arrives? It’s hard to blame them. But data has shown that physicians who make the PCMH transition have much higher job satisfaction and slower rates of burnout. Many doctors feel that they are better able to serve patients, which seems to be the main reason for their higher satisfaction. Patients agree with them, as they too experience higher satisfaction in this model of care. It truly is more patient- and provider-friendly.

Also a likely reason for the hesitancy is the lack of specific guidelines. While the general principles are agreed upon, physicians are trained to think more concretely, and thus seem to struggle a bit with vague strategies. It also seems that doctors like to be told exactly what is expected, so that they know specifically what to complain about! The lack of specific guidelines seems to underscore a lack of local leadership throughout the country pushing for care redesign – though this appears to have improved over the last few years as more clinics are making the transition. The ever-expanding examples of what the PCMH can look like have many different variations while still achieving the main principles. More information is present, and practice redesign is now gaining speed across the country.

Having recently completed residency, I have had many job interviews in the last year.  This time I asked each practice about Accountable Care Organization (ACO) participation. An administrator of a large health system stated, “We don’t yet know what that looks like.” In many ways, ACOs are a macrocosm of the PCMH, and their success will rely heavily on strong primary care organization. While he may not believe he knows what ACOs look like yet, thanks to local leaders and champions, improving payment support, and greater access to other like-minded transformations, he and his system now at least know what the PCMH looks like.

Kyle Bradford Jones is a family physician who blogs at Primary Care Progress.

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