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Friday Oct 04, 2013

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 subsidiarywas 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.


This is a welcome sign of improved awareness. More awareness from health and government leaders is needed about the problems of pay for performance, value based, and readmission penalties that are associated with populations more complex, lower income, lesser employed, less covered, older, sicker, with less healthy habits, and cared for by family physicians.

Posted by Robert C. Bowman, M.D. on October 05, 2013 at 10:12 PM CDT #

Maybe the reason that medical homes are showing improvements in cost efficiency is that those transformed practices were very inefficient to begin with. Having been part of a larger single specialty group in the past, I know for a fact that my current solo practice is much more efficient (as I suspect most other solo FPs are) and am skeptical about the benefit to my patients of transforming into a PCMH.

Posted by Keith Dinklage M.D. on October 07, 2013 at 07:03 AM CDT #

We are a small, 2 MD, 2 NP, family practice office in Oak Ridge TN. We have been using an emr for more than a decade and were one of first practices in Tennessee to attest for meaningful use of our emr. We took the PCMH quiz that is at the beginning of the NCQA recognition application data and actually do function as a medical home. However to receive recognition we need to document our practices. This will take a lot of time and money. Currently no provider in my state will pay us for being a PCMH.

Posted by Jeff Grabenstein, MD on October 09, 2013 at 10:32 AM CDT #

I think the point regarding small practices that is missed by those promoting "PCMH" is that for many small practices, no "transformation" is necessary to provide superb patient-centered care. Many small practices have been early adopters of EMRs, engage in ongoing quality improvement projects, and have excellent access for patients. What we don't have is the ability to meet the documentation requirements of the NCQA, which is designed to make large practices appear to have the qualities of small practices. I am a solo doctor, with no employees, who has had an EMR since 1997, has been collecting quality data and participating in national quality improvement projects since 2003, and who has been collecting patient experience data (using HowsYourHealth?) since 2007. My patients schedule their own appointments on line for as much time as they want, and all have my cell phone number. For me to erect barriers to patient care by hiring staff so that I could have "team meetings" and so that I could develop triage protocols for appointments rather than just seeing people when they want to be seen would be ludicrous. Dumbing down my EMR and making it less efficient so I could qualify for Meaningful Use incentives resulted in a measurable reduction in the quality of care I was able to provide last year. I certainly will not do that again. For me to take the time and energy away from patient care to jump through the NCQA hoops for PCMH recognition would be a great disservice to my patients, and would result in a reduction in quality of care that I am unwilling to tolerate. I would respectfully suggest that practices that are able to provide excellent data on their quality of care and on measures of patient-centeredness should not be admonished to "transform" or to try to meet criteria that were designed for large practices that will never be as patient-centered as the small practices already are.

Posted by Don Stewart on October 10, 2013 at 03:10 AM CDT #

Thank you to all of the previous comments! Clearly I am not alone in believing most solo practices have the culture and customer service technique for caring for their patients across the "medical neighborhood". What I have been affected by is the significant drop in communication by sub specialists and surgeons who have an EMR that does not communicate with a Doc who is not on the same captive EMR(owned by the hospital ). In Cincinnati every hospital is on Epic but NONE of them can communicate directly! Hmmm!

Posted by Will Sawyer on October 10, 2013 at 06:52 AM CDT #

My wife and I are in private practice in rural Ohio. Reading thru the comments already posted, I see we have all the same issues...we have already been providing a patient centered medical home for years but submitting the "paperwork" to support this will be overly burdensome. We have been on EMR for over 8 years now, but rather than improving communication among physicians, physician interchange has been hampered by the current systems available on the market showing lack of ability to exchange data with each other. Before EMR, if I had a difficult case, I could call one of the local specialists and run the case by them. Now, with all the time spent in documentation to prove my quality of care, I barely have time to breath. As others have mentioned, it seems as many of the changes have just raised further barriers between me and my patients. Now we have all this "data" that shows the benefit of the PCMH? Data collected from large health care organizations at least partially if not fully funded by commercial insurance companies? I have yet to see a study proving benefit of PCMH that would meet level I or even level II-1 criteria. Sounds like the drug reps are back at my door touting their latest and greatest! With so many members of the AAFP being in small practice, one would think the AAFP would take more heed of our concerns and bring those before the powers at be, but instead, it appears that the AAFP accepts whatever the powers at be want, and then tells its members to deal with it the best they can.

Posted by Steven Stasiak MD on October 10, 2013 at 01:43 PM CDT #

It seems to me, summarizing from above, that most small and rural practices are not having much of a challenge starting EMR or even transforming to PCMH, but it is the recognition (specifically NCQA) that is the biggest hurdle, especially since most places are not paying more for that recognition. Is that correct??

Posted by Dan Spogen on October 11, 2013 at 10:12 AM CDT #

Thank you for the attention to small practices. I have been in a solo practice for >10 years and have an EHR, open access, and 24/7 coverage via cell phone. I have been involved in numerous research projects which have consistently shown my patient centered data is far better than average. Yet, echoing the other voices, to get NCQA certification is a horrible waste of time and will actually make care worse as I spend time trying to certify. Here are the issues I see and potential solutions: 1) We need to use the leverage of the AAFP to get claims data for small and solo practices on a state by state basis so this can be compaired to larger/corporate practices and national norms. If we do not have claims data showing how we are doing, we have no negotiating power with the payers. 2) We need to find a single universally accepted metric by which to measure primary care. This metric would measure the 4 pillars of care: access, continuity, comprehensiveness, and coordination. Note: If you go through the litany of frequently used metrics including NCQA, HEDIS, Meaningful Use, etc, none really measure the above pillars but instead have shifted attention to the collection of disease based information. Starfield noted regularly that disease based information is great for specialists, but fails to fully measure primary care. She also stated that disease is a made up construct because it does not exist in isolation, and that we have to remember the patient is not the sum of their diseases. And yet, we continue down this dead end path. Those of us in small practices have intense and lasting relationships with our patients. We understand that it is the relationship that is important not the checking of a box in our EHR (ex. verification that we have check the HGBA1C in the past 6 months). Box checking is peripheral to where our focus should be and is therefore a lower priority. Instead of focusing on form (ex. make everyone do certification for X or Y), we need to put the focus back on function (high quality primary care). Let the wonderful docs who do this every day have the autonomy to figure out solutions for their patients and practices. Of course, this step can only be accomplished by having an accurate patient-centric metric which augments what we do and by having the breathing room (allowed by better and more intelligent reimbursement) to assess our practices and make improvements. 3) The AAFP needs to develop a white paper discussing the value of small, independent practices to the health of our nation. This may seem trivial, but there are numerous voices who believe "individual silos" of care need to be abolished. We need a strong paper defending small practices. 4) We need to know the AAFP is interested in helping. The AAFP needs to use its database to reach out proactively to small and solo practices and see how they can help. We need support now. We need to know that in these difficult times, the AAFP is still a voice for the small doc. 5) All this has to happen in the very near future. The way medicine is changing, there aren't going to be many of us left in 5 years. If there is value to small practices, and it will have to be proven, we need this expressed soon.

Posted by John Brady on October 17, 2013 at 03:39 PM CDT #

The problem with the PCMH is simple, There are no decent EHR's on the market. We can dictate all our notes, in front of the patient, in 1/4 the time it takes to input all the EHR's we have evaluated, and we have evaluated all the top scoring EHR's in the FPM magazine. Dictating is so much more efficient that we have totally given up on the PCMH and EHR's and we will be glad to take the 3% hit from Medicare, it does not nearly penalize us enough to make up for the inefficiency and transformation to the current EHR's. I believe that the AAFP wasted a fortune on the PCMH, because most excellent Practices were already a PCMH. After all, isn't that the point of Family Medicine? WHAT SHOULD HAVE BEEN DONE WAS TO DEVELOP AN EHR THAT IS AS INTUITIVE AS A MAC COMPUTER! It is still possible, and until the AAFP or some other organization does this, we will keep on dictating. Ken Sherman M.D. Elgin, Texas

Posted by Ken Sherman M.D. on October 26, 2013 at 02:54 AM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.