March 14, 2014

PCMHs Require More Than Just Seeing Patients

Patient-centered medical homes (PCMHs) are supposedly here to stay under two laws. This is a critical part of almost every aspect of the Affordable Care Act and HITECH. However, cultural attitudes, fears and logistical obstacles hold back the reform set up by these laws.

The medical news has been full of this story for much of the prior week, but I think there is more about this than we are receiving. The facts as reported from a 3-year study of 32 small and medium sized primary care practices and multi-payer pilot:
  1. A PCMH demonstration project could not significantly reduce costs and utilization or improve quality of care.
  2. A PCMH model didn't reduce hospitalizations, emergency department use, ambulatory services, or costs.
  3. The practices showed improvement in only one of 11 quality measures -- nephropathy screening in diabetes patients

Thomas Schwenk, MD, dean of the University of Nevada School of Medicine in Reno, wrote in an accompanying editorial. "Widespread implementation of the PCMH with limited data may lead to failure." Instead, the study should remind the healthcare community that providers' focus should be on high-need patients, he said.”   Bold is my emphasis.

A quarter of all medical care is consumed by 1% of the population, according to the Agency for Healthcare Research and Quality. And nearly half is consumed by 5%. It's those patients who would benefit from extra care management and oversight that are usually trademarks of PCMHs, Schwenk wrote.”

Now there has more to the article, but I have some questions about the study. The one editorial by Dr. Schwenk above about high-need patients make me wonder what is being hidden by the study and why he would chose this term to emphasize about PCMHs. Are they considering reducing the consumption of the 1% and 5% patients and to what extent? Could it be the doctors in the study were not willing to short-change the treatment of high-need patients?

The last question leads me to another article in Government Health IT. Here Dr. Russell Kohl states that physicians should start learning to dance with their patients, instead of wrestling with them.

I can relate to the analogy Dr. Kohl uses to emphasize his point. When we consider that there are 525,600 minutes in a year and if a doctor sees a patient four times a year for a generous 30 minutes per visit, the doctor might get to spend 120 minutes a year with each patient. Doctors think that the 120 minutes as the most important in patient engagement.

The patient, on the other hand, does not consider them the most important of their year. How do doctors leverage the rest of the time to help patients take care of themselves? This means moving away from doctors knowing everything and bestowing care upon their patients to help patients take care of themselves. The patients do have 525,480 minutes to devote to that.

These are my thoughts. This means that doctors would actually have to communicate with the patients which doctors are ill equipped to do, as they only understand patient engagement. For many doctors, the word communication is a foreign language reserved for their family and not patients.

Dr. Kohl believes many patients are already active in their own care, and “grandma” surprises everyone by being the most actively engaged using patient portals. Whoa, most doctors are afraid of the portals. Doctors view patient portals as an opportunity for patients to drain them of their time. Dr. Kohl likes to show them how much time can be saved by emailing with their patients.

Dr. Kohl also has other tools for building the kind of relationship necessary for a patient-physician partnership. He says this includes home visits, personal written notes that help patients see the progress they are making in improving their health, even if it is a very small improvement.

The last question is why are doctors so reluctant to use true communication. My favorite blogging doctor, Dr. Rob Lamberts says, “Communication isn’t important to health care, communication is health care.”

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