Challenges, Hope for Small Practices and PCMH
One of the interesting things AAFP Board members get to do is travel to state chapter meetings. This is a great experience because we get to hear the issues that concern our members from across the nation.
One question that has been posed to me multiple times at such meetings regards the challenges small practices face in transforming to the patient-centered medical home (PCMH) model.
There are volumes of data supporting the transformation to a value-based, rather than a volume-based, system. The change results in better patient health outcomes at lower health care costs. Unfortunately, however, most of the available data comes from large practices, and the costs involved in making the transformation often are covered by higher level evaluation and management (E/M) coding, as well as shared savings from reduced emergency room and hospital expenses.
The hope of a blended payment system is on the horizon, but it isn't incorporated yet in most markets. Small practices often don't have the internal support to make the transformation and often don't get the advantage of lower overall health care costs.
The question frequently posed to me is, does transformation make sense for the small practice?
Some small practices have made the transformation and reaped the benefits. But some have suffered financial ruin when trying to make the change. One member told me she had to close her solo practice after moving to the PCMH model. After starting her electronic health record (EHR) and making adjustments to make her practice a PCMH, she went bankrupt. Although she was able to charge more per visit in the new practice model, her visits took longer so she saw fewer patients.
She was not able to collect on the patient portal encounters through insurance. Visits by her nurse and nutritionist were not well compensated. After 20 years in practice, she closed her doors and went to work for a large multidisciplinary group in another town. Now she is away from home 20 days a month and is not happy with the change.
My own residency practice had issues as well. We did not have insurance support paying for some of the PCMH attributes, and the higher E/M charges did not outweigh the longer patient visits. We ended up going back to a volume-based system to survive.
What about the bigger picture? Thirty-eight percent of AAFP members practice in groups of fewer than four providers. There is no data available to tell us how many of these practices have transformed to the PCMH model, but we do know that 57 percent of our small practices have started implementing EHRs, which might be the first step to PCMH recognition. Conversely, 85 percent of our large practices have converted to EHRs, so it seems that those larger practices may have more infrastructure in place to support change.
One of the four strategic priorities of the AAFP is practice enhancement. One of the main goals of this area is the transformation of all family medicine practices to the PCMH model. Another priority in practice enhancement is improved payment for family physicians. It is difficult to separate these two issues because to transform one's practice, it costs both time and money. Our Academy realizes this and is advocating for better payment for primary care and even enhanced payment for those who offer the attributes of a PCMH. The eventual goal would be to have a blended payment system that would incorporate a per-member, per-month base fee plus a fee-for-service payment and a pay-for-performance payment.
The Congress of Delegates asked the AAFP to study the impact of PCMH transformation on small practices last year, and a study on the topic was published earlier this year in Annals of Family Medicine. However, only practices that have achieved National Committee for Quality Assurance recognition were included in the study, which acknowledged small practices that have achieved recognition did so as part of local demonstration projects or with help from financial incentives or other support.
What about practices that are attempting transformation without the benefit of a demonstration project or grants? And what about small practices that have attempted practice transformation but were not, or have not yet been, successful? What has stopped them, and what could make a difference?
Clearly, we need more research on practice transformation and the barriers that small practices face.
The overall cost to transform a practice from a standard, paper-based practice to a PCMH with an EHR is roughly $100,000 per full-time equivalent physician overall. But is this true for small practices? Is the cost more or less? When overall health care costs decline, are the savings shared with the small practice providers?
Do the better health care outcomes seen in large PCMHs translate to small practices? It would seem so, but the evidence is lacking.
So, is there hope for small practices that want to transform to PCMH? The answer is yes.
TransforMED, the AAFP's wholly owned, nonprofit subsidiary, was created in response to the Future of Family Medicine Project to help practices make the transition to the PCMH model, but initial efforts to engage small practices met with little success. The reality is that many small practices lacked the necessary capital to invest in practice transformation, and some did not value consultant services.
The market imperative for TransforMED was to serve health plans, multi-specialty groups and integrated systems because they had the money and the understanding that change facilitation was needed to accomplish this work. As a result of its commercial success, TransforMED has grown and now offers small practices access to information, expert advice and tools on DeltaExchange, which is free to AAFP members.
Many of the changes required for PCMH have to do with organization and workflow and may not be expensive to implement. Small practices can begin the transformation while still in a fee-for-service environment, but the real change will be accelerated when blended payment, global payment and payment for value become the norm.
The Academy soon will offer another resource that will help members transform their practices. The PCMH Planner, which likely will be launched early in 2014, was promoted and available for a "sneak preview" during Scientific Assembly last week in San Diego. The Planner is an online software subscription tool that will help practices assess their needs and provide them with step-by-step guides and links to resources to help them complete PCMH transformation and achieve meaningful use. AAFP members will receive a discounted price when they subscribe to the tool.
As a member benefit, the Academy's Division of Practice Advancement also has subject matter experts available to answer questions about PCMH and provide free resources on the topic. You can connect with them through the AAFP Contact Center at (800) 274-2237.
Finally, last week in San Diego, the Congress of Delegates adopted a resolution that calls for the AAFP to study EHR adoption and PCMH transformation by family physicians who may face additional barriers to change -- including age, practice size and rural location -- and determine the best ways to help them stay in practice.
The Congress of Delegates also referred to the Board of Directors two resolutions that asked the Academy to form a special interest group devoted to physicians in solo or small-group practices. The Academy already has a task force -- chaired by AAFP President Reid Blackwelder, M.D. -- working to determine how best to serve the needs of specific membership groups. That task force met last month and is scheduled to meet again early next year.
I would be interested in your comments about PCMH implementation for small practices and what more the Academy can do to help. Also, it would be interesting to know about small practices that have successfully transformed to a PCMH and how you were able to do it, so we could share best practices with other members.
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
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