As someone whose practice has included both general internal medicine and nephrology, I understand the sense of uncertainty among both generalists and subspecialists over the patient-centered medical home (PCMH). When discussing the PCMH as a model for delivering health care in the U.S. three questions commonly arise:
1. Why does the ACP, with nearly equal numbers of general internists and subspecialty internists, advocate for a system that appears more beneficial to primary care physicians? 2. How will my practice and patients' experiences change? 3. Why should subspecialists support this model?
Why ACP supports the PCMH
The most important factor when assessing any possible change to the system is whether the proposal is best for the patient. ACP has extensively reviewed and published available data from this country and abroad. Had the data shown that patients were best served by emphasizing individual organ care, the College would have supported expanded subspecialist roles; but the data compellingly suggest that the U.S. can best improve outcomes and control costs by expanding primary care.
Bolstering primary care requires enhancing reimbursement. Funding should support a team of caregivers, led by the physician. To enhance reimbursement, the ACP advocates three sources of payment: A bundled payment for care coordination and health information technology (HIT), a performance-based component to recognize quality and efficiency and to promote continuous quality improvement, and a visit-based fee-for-service payment to incentivize physicians to see patients in the office when appropriate. Collectively, the compensation must be enough that young people with average educational debts of $140,000 (or $280,000 as is the case with the increasingly common two-physician couples) will be more interested in pursuing the personal and intellectual satisfaction of careers in primary care.
With overhead expenses accounting for an average of 60% of a practice's costs, primary care physicians now are forced to see patients in 10-15 minute intervals, no matter how complex the case. Within a PCMH, internists should be able to devote additional time to patients with multiple chronic diseases and regain the satisfaction of caring for patients over many years.
Consider some of the advantages that a PCMH practice could offer patients:
- innovative scheduling systems to minimize delays in getting appointments,
- non-urgent medical advice by e-mail and telephone,
- same-day care with PCMH-based non-physicians for less complex issues,
- group teaching of patients with chronic diseases,
- time for coordinating care with family and other clinicians,
- evidence-based point-of-care support tools, and
- better HIT to efficiently coordinate all sources of the patient's care within the community and to track quality and patient satisfaction measures to promote continuous improvement.
How it benefits subspecialists
The third frequently asked question is “Why should subspecialists support the PCMH?” First and foremost is the need to improve patient care. Compelling evidence suggests that expanding the primary care base of internists, family practitioners, and pediatricians will improve outcomes. In some cases subspecialists would lead PCMH-type care if, for example, a patient's health care needs are centered on complex single-organ issues, such as end stage renal disease.
Also consider the following:
New billing codes. Both those subspecialists and generalists who prefer not to provide all the components of a fully implemented PCMH would still be eligible to use new billing codes that compensate physicians who participate in the coordination of care and/or provide some of the aspects of the medical home, such as e-mail responses to patients' questions or group teaching.
Fewer hassles. The PCMH should maintain smooth links between the patient's medical records, hospital records, consultants' findings, pharmacy, medical equipment providers, occupational and physical therapy, home care, and nursing home care. Subspecialists should need fewer administrative personnel when the PCMH, with adequate HIT, becomes the ready access point for information relevant to the patient.
Better referrals. Subspecialists often complain that patients arrive from the primary care physician without even a basic diagnostic workup. Given more time with patients, the primary care physician can resolve low-intensity issues and eliminate needless referrals, allowing the subspecialists more time to sort through complex cases.
Improved quality of practice. A thriving primary care workforce can handle patients' preventive care, acute care for less complex problems, long-term management of broad chronic problems, and end-of-life care. Subspecialists can pursue the more focused practice that they enjoy and for which they were trained.
Efficient spending. Neither public nor private payers are willing simply to spend more money to raise the wages of primary care physicians. Absent other resources, the current “budget neutral” climate means earnings disparities must be narrowed by shifting funding from one group to another. Public and private stakeholders believe that the PCMH is the most promising solution for health care reform, leading to savings that could be the source of funding for primary care and which could eventually fund coverage for the currently 47 million uninsured.
Our health care system is unsustainable. There is near universal recognition of the need for a new model of delivery. I hope the responses cited to these three commonly posed questions help allay some of the concerns over the PCMH. Patients, generalist internists, and subspecialist internists ultimately benefit from strengthening primary care through the PCMH model.