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Monday Feb 18, 2013

Residencies Face Barriers to Teaching PCMH

I believe that the patient-centered medical home (PCMH) is the future of primary care. The model has been proven to provide cost effective and high quality health care, and some payers are beginning to recognize its value.

At the University of Nevada School of Medicine, where I am chair of the department of family medicine, we have developed curriculum for students that includes required reading, faculty lectures and shadowing faculty. It's working out well for student education.

But in Nevada, and elsewhere, teaching the PCMH model to residents remains an issue that needs a solution. It's a looming problem for residencies because, starting in 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require residencies to teach population management. Although population management sounds big and broad, the reality is that PCMH is the most likely model to fill that accreditation requirement.

According to an estimate by the Association of Departments of Family Medicine (ADFM), one-third of residencies already are teaching PCMH, one-third are working to implement it into their training programs and one-third have made no progress in implementing it.

That leaves many programs with a lot of work to do in the next two years. Unfortunately, adding curriculum with no new resources amounts to an unfunded mandate. How will these programs adjust?

The good news is that help may be on the way. For years, the AAFP, and a coalition of other primary care groups, has been urging the Health Resources and Services Administration (HRSA) to study the development of PCMH curriculum in primary care residencies. A pilot project, funded by HRSA, is expected to start this spring at four universities (encompassing a total of 12 pediatric, family medicine and internal medicine residencies).

The goal will be to develop a unified curriculum that could be deployed in any of our nation's roughly 1,000 primary care residency programs.

Of course, the lack of standardized curriculum is just one barrier to making a residency program a PCMH. Population management is impossible without a robust electronic health record (EHR) system, and some programs just aren't there yet.

It's estimated that implementing an EHR in private practice costs roughly $80,000 per full-time equivalent physician. Here in Nevada, we have six departments in Las Vegas and four in Reno. The cost to implement our new EHR is estimated at $6 million. For some training programs, the cost will be even higher.

Grant money has helped some residency programs move forward with EHR implementation, but others lack the resources to take that step, which is a shame because the PCMH is good for patients. It stresses preventive care, engages the patient and encourages a healthy lifestyle. It also benefits payers by lowering costs, improving care and leading to better outcomes.

We can talk to our residents about PCMH, and we can teach them about things such as team-based care. But without an established curriculum and robust EHRs, residents are only getting a taste of what the PCMH is all about.

And those who don't learn the PCMH in residency will be forced to learn it as new physicians. Surely, there is a better way. We need a consistent method of teaching PCMH at all levels of education.

Payers stand to reap the benefits of physicians who practice in the PCMH model. So payers should recognize that teaching students and residents in this model is costly and do what they can to help facilitate that training.

Daniel Spogen, M.D., is a member of the AAFP Board of Directors.


I don't really understand how the Patient-Centered Medical Home saves much money to the healthcare system outside of reducing visits to an Emergency Dept. or maybe attempting to keep patients healthier through intensifying screening tests & promoting healthier lifestyles (both of which I am already doing to some extent without being an official PMCH. Upfront costs for this model are high and I'm pessimistic that the increased payments for "quality care" will come close to replacing lost revenue from multiple daily acute care work-in visits for which there will no longer be appointment space. Any other thoughts?

Posted by Bryan Ellenberg MD on February 20, 2013 at 06:49 PM CST #

I am unaware of any PCMH of a population scale other than a pilot that has been cost effective without being another name for capitation. I hope we as physician are not expected to be actuaries in addition to medicine. There are many unanswered questions about PCMH and those questions will need to be answered before it will be accepted generally. Many of those questions are more than just about reimbursement. One of those questions is that pilot projects are supported with grants and special populations in order to study effectiveness of the model--when will it be effective to a significant general population which absorbs all of the expense of the model? Another one of those questions is how will it handle problems such as the flu vaccine for this year? Nearly 40% of the current vaccinated individuals caught influenza in my practice whereas more than 60% of the unimmunized individuals in my practice did not report being infected with influenza (I can now see those type of numbers from an EHR). Problems such as this really do not help PCMHs become cost effective and digitalized data allows a great deal of scrutiny which was not seen in prior years. I like the idea of PCMH but am not convinced that it is a cost effective model that can be applied to my practice.

Posted by Peter Lueninghoener MD on February 22, 2013 at 10:04 PM CST #

"The (PCMH) model has been proven to provide cost effective and high quality health care" I strongly disagree. I don't think either of these has been proven. It is embarrassing to see AAFP leaders continue to refer to the PCPCC paper as some sort of evidence. The majority of the "reports" included are unreviewed press releases from profit -oriented insurers. The larger studies included have been vigorously attacked: for example, the much-touted North Carolina Medicaid project has been shown to be a complete sham, and may even result in criminal charges. We get much accurate information from Solberg Annals of Family Medicine 11/11 (visciously attacked by the AAFP brass) and Jackson Annals of Internal Medicine 2/13: both showed no to insignificant improvements in cost and quality with the PCMH model (and, as Dr. Lueninghoener indicates, that's without even addressing what subsidies were required to produce these unimpressive results). I do agree, Dr. Spogen, that the PCMH is an "unfunded mandate:" sadly, one that is being forced on us by the organization on whose board you sit. We've been telling the AAFP for the past decade that their insistence that we invest in the time, equipment, and staff needed to become a PCMH and then hope that someday someone pays us for it, is absolutely the worst possible business plan for family physicians at this time. And we have been totally ignored. Now with your personal insight, maybe you could convince the Board to finally discuss this? Thanks

Posted by on February 26, 2013 at 01:54 PM CST #

Having personally cared for a multitude of patients as part of PCMH team care at an FQHC, as well as at the two local hospitals my patient population utilizes, I am aware on a case by case basis how often I am saving hospitalizations, duplications of procedures, polypharmacy, etc. by knowing my patients not only from my own continuity perspective in 10-15 minute visits, but also from the perspectives of my behavioral health specialists, my clinical pharmacologist, my organization's pharmacists...the information I glean from these team members is invaluable. As a hospital service at our local hospitals, our physicians perform better than hospitalists on readmissions and outcomes. I fail to see how arguing about whether implementing the principles of the PCMH will be too expensive should drive us away from providing quality care for our patients. When our patients and legislators recognize us for our concern, compassion, and quality (and we contribute to our PAC and personally advocate for our patients about PCMH to our legislators), CMS and private insurers will have no choice but to continue to contribute money to studies about PCMH outcomes. I have a feeling reimbursements will then follow.

Posted by Christopher Baumert MD on February 26, 2013 at 05:42 PM CST #

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