At a certain point in the lifecycle in any business, the predominant business model gets exhausted.
Medicine is a case in point. The dominant U.S. business model—visit based, fee-for-service—is slowly buckling under the crushing cost burden it is imposing our society.
Although it will take awhile to transform this $2 trillion bloated behemoth into a system that offers better care at a lower cost, there are flurry of movements under way that are both interesting and promising. One of the most interesting and most promising is the patient centered medical home (PCMH).
What is it? It is a primary care practice that puts together a mix of people, process, and technology so that patients get better care and better customer service. It also intended to help increasingly burnt-out providers step off the 30 visit a day rat-race and reconnect them to a more satisfying and less frantic patient care model.
At the people level, the PCMH emphasizes teams of care providers vs. strict reliance on the physician for all clinical and patient decision making. The teams consist of doctors, PAs, nurses, medical assistants—and even administrative staff. This does not mean that the receptionist is making diagnoses, but rather provides the basis for a more coordinated effort to meet patient needs both before and after the visit. A simple example: a patient is referred to a cardiologist. Did they go? Has the practice received the documentation of the visit? Physicians are not going to track this, but a team member certainly can.
At the process level, the PCMH require practices to think about their practices not as a visit factory organized around the availability of overworked providers, but as a patient-centric service center, where it is easy for patients to make last minute appointments and communicate with the care team as question arise.
A PCMH also brings an element of practice accountability to patient care: Am I managing my diabetics effectively? Are my cardiac patients adhering to the recommended meds? This is a distinct switch from the predominant model of reactive medicine to a proactive approach. This can have a big payoff for the management of chronically ill patients that consume much of our health care dollars.
It is impossible to implement these people and process changes without technology. The technology centerpiece of the medical home is the electronic health record (EHR), which provides not only a repository for patient information, but can also trigger preventative reminders based on the patient’s condition, plus practical tools such as e-prescribing. The EHRs make the patient record universally available to anyone with access to a workstation—a critical requirement for team based care.
While EHRs are very well suited to individual record keeping, they may not be as well suited at looking at populations of patients (i.e. How many of my diabetic patients are well controlled for HgA1c?). To help answer these questions some PCMHs may use a disease registry (more technology) to track patients. Finally, since patient engagement and easy access to providers is a core element of the patient centered medical home, many are adopting patient portals and secure messaging to provide an alternative to traditional phone and fax communication.
Does the PCMH work? At least one study suggests that they do. Research done by Seattle-based Group Health’s medical home pilot (published in Health Affairs in May of 2012) indicated that medical home patients (when compared to patients in traditional Group Health practices) had 29 percent fewer ER visits and 6 percent fewer hospitalizations, with a net savings of about $10 per patient per month. The data also suggest improved patient satisfaction and happier providers.
The downside: setting up a PCMH is hard work and expensive (team based care means more practice FTEs per patient). However, the PCMH model that is not going away and is fully aligned with the necessary shift from quantity to quality in American medicine. It is the right approach.
What questions do you have?
Bruce Kleaveland is President of Kleaveland Consulting and a sponsored health IT correspondent for Intel