Achieving PCMH Status May Not Be Meaningful for Small Practices

I am grateful to Drs. Glancey and Kennedy for their excellent commentary and saddened by what they report. Here are two family physicians that go out of their way to provide exemplary, transformational primary care. A true PCMH, they provide the fundamental tenets of primary care, a new way of organizing practice, development of internal capabilities; and related health system and reimbursement changes. [1] They comply with demands of governmental programs such a meaningful use, have a focus on quality improvement and participate as a CPCI practice. Yet all these changes are threatened by what is the tyranny of what Berwick calls " era of complex incentives and excessive measurement". [2] A sentiment also decried by the recently released National Academy of Medicine (formerly IOM) report Vital Signs: Core Metrics for Health And Health Care Progress. [3]

Their experience, investing significant amount of effort and time reporting the required measures and obtaining the desired outcomes produced reduced payments that may make the changes unsustainable financially. The reductions are in part due to measures, such as hospitalizations, which may be easy to collect but not representing the value of what they deliver in the context of their practice. Such is the paradox of primary care transformation in the current measurement climate. There is an urgent need to develop measures that truly represent the value that primary care brings to the patients and communities we serve. The effort that the American Board of Family Medicine has initiated with the development of a national registry for Family Medicine is a step in the right direction that may provide the opportunity to develop such measures. [4] Transformation is required to deliver the promise of advanced primary care but toxic measures must be eliminated for the improvement to be sustained. A limited set of measures that guide improvement in processes and outcomes and that are meaningful to patients, clinicians and communities are urgently needed.

1. Stange, Kurt C., et al. "Defining and measuring the patient-centered medical home." Journal of general internal medicine 25.6 (2010): 601-612.
2. Berwick's 9 steps to a new 'moral era' in medicine. (2015, December 30) Retrieved from http://cmg625.com/berwicks-9-steps-to-a-new-moral-era-in-medicine/
3. Blumenthal, David, and J. Michael McGinnis. "Measuring Vital Signs: An IOM Report on Core Metrics for Health and Health Care Progress." JAMA 313.19 (2015): 1901-1902.
4. Phillips, Robert L. "ABFM TO SIMPLIFY MOC FOR FAMILY PHYSICIANS AND MAKE IT MORE MEANINGFUL: A FAMILY MEDICINE REGISTRY."The Annals of Family Medicine 13.3 (2015): 288-290.

Competing interests: None declared

After the terrific analytics by our ABFM colleagues, the experiences of a cutting edge community practice, the observations by a national leader of health information tech, and a cry from the heart from a brilliant policy leader in our field, I wonder what I can add that will move this conversation forward.

My own position is in a small independent practice with an outsize population in the Bronx for 35 years, and as an independent researcher in implementation in continuing education in the health professions, as well as a voice on education policy for our installed base of health professionals. I view our task as bringing into alignment communities, public health officials, and healthcare providers, and building the continuing educational communities and collaboratives that will restore the abysmal health of the US public.

That's why we learn, that's why we practice and teach, and that is why we engineer and implement the future, with our communities and our policy makers.

My medical education in East Harlem occurred in the environment of not-for-profit health care--not great, but leading the world. As I completed my National Health Service Corps work, the Reagan revolution institutionalized for-profit health care--not so great, but with some momentum as the big investors looked to make profit on providing care. Health data's curve bent down.

With the collapse of the original Clinton health plan, as my Bronx practice was comfortable but not enriching, investors pivoted to health care as a financial profit center, which is not how you and I see it, but rather as a way to make money on transactions--bonds, buying of systems, creations of amalgams of systems and insurers. The business school model is the monetization of all aspects of the system in order to maximize transaction profits, including the monopolization of services. One does not focus on product, but on selling the business or the bond. Which is why EHRs look like they look. And the world's health stats improved faster than the US's.

The bottom line? One needs a good bottom line to attract capital to purchase the next hospital/clinic/group, so we see layoffs at institutions intent on borrowing to buy and expand, in order to command attributed lives. My payments took a nose dive.

Where does the capital come from, with institutions presumably working with very narrow profit margins? We have not seen a good analysis of this, but more and more, this capital seems to flow from large insurance carriers working with financial institutions and funds to issue bonds that look very much like the collateral debt obligations of the last real estate crash in 2008, without much oversight and very little reportage. One of the last three national insurance carriers already has a strong grip on pharmacy benefits management, the relative value manual, and new narrow insurance panels that exclude many small practices, like mine.

Of course, we have much published analytics [including some mentioned by Dr. Mostashari] demonstrating the null value for patient outcomes [let alone outcomes important to patients] of performance-based payments. Indeed, the sample sizes needed to show replicable change at the 10% level for most measures over time is quite large, usually well over 200 providers and thousands of patients with comparable conditions, and also hard to analyze with current systems, given temporal and other changes as well as the huge confidence limits of the data sets. Not to leave out the intrinsic uncertainties of massive data sets and administrative data.

Value based payment implementation is based on math that would not ordinarily be publishable. Multiple ethical quandaries also prevail. Do you inform your patients that you will be paid more if they take their pills, which might be of marginal value?

But the Buffalo stampede continues [forgive me, I do like the city and the beasts] to monopoly systems that support narrow insurance panels, leaving out the small independent practices like mine that have low ED and ambulatory care sensitive hospitalizations [as much as the numbers have any validity], and high satisfaction and organic and trusting connections to communities, like mine.

The NYCDOHMH has so far found [and this is a tough slog through data, but they are clever] that 40-60% of medicaid patients in NYC are seen by very small primary care practices, like mine, many of which are linguistically and culturally congruent with their communities.

OK-the worst for last. These new systems are not only too big to fail, but are over-leveraged in many cases. Without the payments to cover their debt service, they will struggle. Are we as a country ready to bail them out?

Competing interests: None declared