PCMH meets the real world

The “preliminary” report on TransforMED is out, and it isn’t pretty. It also isn’t much different than Evaluators’ Report #5 from over a year ago. If you’ve never heard of the Patient-Centered Medical Home (PCMH) or TransforMED, I’m not going to help you today. See old blogs here and here, which will link you to the big picture. 

First, some perspective.   

The AAFP deserves a lot of credit for at least three reasons. First, it recognized several years ago that the specialty was in trouble and came up with an action plan. Second, it put its money where its mouth was, to the tune of $8 million, and funded an experiment to see if its plan was workable. Third, when the results weren’t pretty (see below), it didn’t flush them, and we know that that has proved to be a big problem in medical research. 

The AAFP also deserves three Bronx cheers. First, it has tirelessly promoted the PCMH model (as defined by TransforMED) to its membership without having the evidence to back it up. Second, it is allowing TransforMED to sell its non-evidence-based services to members. Third, it is failing to provide a forum for the vigorous debate that needs to take place immediately. 

What follows below is a cut-and-paste summary of the “Initial Lessons” from the researchers' report with my brief commentary in italics. 

Rush to Judgment; Unintended Consequences; Hold Your Horses: "The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and financial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA), risks premature closure of the larger PCMH conversations and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs. … The pressure toward widespread adoption of this model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. … The NCQA has taken the lead in defining some essential components and creating a 3-tiered, implementation process for recognizing a PCMH. We fear the details of the recognition process may have reached premature closure, however, before the rich data have emerged from the NDP and other current demonstrations."

A one-size-fits-all approach is usually a bad idea, and TransforMED has proved it. The PCMH is ideally suited to large practices where bureaucracy has created layers of separation between providers and patients. For small group or solo practices, which constitute the bulk of the AAFP membership, the PCMH prescriptions are an insult. (If you’re not insulted, take the TransforMED Medical Home IQ test. You will be.) The authors are pleading for a re-evaluation of the concept. A good starting point would be the proposal by well-known researcher Barbara Starfield, MD, MPH.

Demoralization; Emotional Exhaustion; Financial Disaster: "In the process of working with these practices, our team has seen the day-to-day reality of changing community-based practices into the current idealized model of the PCMH. We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure. … All the well-supported NDP-facilitated practices were challenged financially by the project." 

At the AAFP's annual meeting in Chicago two years ago I buttonholed Terry McGeeney, TransforMED's president and CEO, and Jim Arend, its CFO and practice facilitator, and asked them about the lack of “before and after” financial data for the participating practices. Their response: “It’s too hard to gather.” So now we know from the researchers' report that the practices were “financially challenged,” but we have no idea how badly. Somebody in authority needs to know what is going on.

Loss of Focus; Perils of Transformative Change: "Most current practice models are designed to enhance physician workflow. The PCMH should be designed to enhance the patient experience. This shift requires a transformation, not an incremental change. … The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, and financial distress. … Do not be surprised if the situation seems worse after the first 6 months to a year; the experience of benefits often takes at least 2 years."  

In a one-horse practice, “the patient experience” is right in your mug all day long. If you miss it, you’re too dense to profit from the PCMH experience anyway. In a big group practice, if you can hold your breath for two years you might be OK, except that all of the TransforMED practices were heavily subsidized financially; so while you’re holding your breath, you’d better be applying for Robert Wood Johnson Foundation grants. And get ready to suffer the consequences of staff burnout and turnover.

EMR Idolatry: "The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. … For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. … New Web-based technologies, electronic clinical information systems, and telecommunications are finally nearing accessibility and utility for both health systems and primary care practices. … Future PCMH recognition and certification processes should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the disease management and information technology features of the PCMH." 

Challenges to the politically expedient push for EMRs are now rolling in from all directions. If you already have one, keep and improve it; if you’re starting practice, research and buy one. If you’re well established, an EMR is not going to make you more money, and will cost you a fortune in purchase, maintenance and lost productivity. 

Productivity and Efficiency: "We should be wary of industrial-like schemes and excessive use of the language of productivity and efficiency. Primary care, like healthy food, works best at a local and personal level."

There are two metaphors for productivity: the factory and the farm. To a good family physician, you cannot view your patients as widgets rolling off an assembly line; they are crops to be nurtured. You can’t hurry the growth of a plant, but you can nurture it more productively. That’s the metaphor this blog is about. On the other hand, the PCMH is more like an industrial operation than anything else; and a bad one, to boot. TransforMED proves it. Now it’s time to move on to greener pastures.

Posted at 10:13AM Jun 11, 2009 by Doug Iliff  |  Comments[2]