2014 will see the beginning of the insurance exchanges and increased access to health insurance coverage for millions of Americans. There is an expectation that having insurance will make healthcare more readily available to those who are presently uninsured. Unfortunately, this vision may not turn out to be the reality — at least not in the manner envisioned by policymakers.
One of the principles underlying the healthcare reform package is that in order to control costs and improve quality, healthcare will need to be integrated and coordinated at the primary care level. The idealistic view of best-practice primary care is that every patient will have a patient-centered medical home (PCMH).
As a member of a family physician practice that combines ambulatory and urgent care, I have seen many elements of the medical home model in action. While its aims are certainly desirable, I feel its proponents have overlooked certain day-to-day realities of practice and patient care. Based on my experience so far, I'm concerned that PCMH will burden our already-strained primary care system without significantly improving outcomes for patients.
According to guidelines established by consensus of several primary care organizations, a PCMH includes:
- A personal physician in a physician-directed, team-based medical practice
- A whole-person orientation
- Coordinated and/or integrated care
- Quality and safety
- Enhanced access and payment
These are lofty goals and hard to disagree with in principle. But there are a number of factors that may make it difficult — if not impossible — to make this model of care achievable in much of the country.
The first issue is that there is already a shortage of nearly 30,000 primary care physicians nationally. Most physicians are already working long hours taking care of their current patients. Where are we going to find a "personal physician" for the 29 million expected to join the ranks of the insured?
A second and huge issue for primary physicians: where are they going to find the time, the dollars and the staff to really help coordinate care for their patients? While there has been some movement in the direction of compensating services beyond face-to-face clinical visits, this is more theory than reality for most insurers. Unless physicians are practicing in one of the large, truly integrated groups such as Kaiser, they most likely cannot afford the infrastructure and support to manage every aspect of the "whole person's" healthcare. This is particularly true for sicker patients and those without the social resources or healthcare literacy to actively participate in their own care.
Enhanced access is the next problem. Most primary docs are already working 40-plus-hour weeks and have appointments booked out weeks or months in advance. The PCMH is supposed to offer same-day appointments and extended hours. If these practices are already bursting at the seams, and the docs are already working full-time, how are they going to increase their capacity? Physician assistants and nurse practitioners can certainly help, but there are shortages of these providers also. Experiments like group visits and telehealth visits are being piloted in various locations. None of these are quite ready for prime time yet, and they certainly do not seem tailored to providing personalized care.
No one would argue with the need to provide high-quality care and make patient safety a top priority. But what exactly constitutes quality and safety? Is checking HgbA1C in a diabetic a mark of quality? Does the value have to fall within a certain range to count? And what about the patient who refuses testing, even when the reasons have been carefully explained? Physicians can only recommend and educate — we cannot compel patients to act; so there is some unfairness in penalizing doctors financially when they have suggested the best approach and the patient just ignores the advice.
The last issue is payment. Medicaid, at least in California, does not pay enough per visit to meet the overhead costs of seeing the patient. While there is currently a bump in Medicaid payment levels, it is temporary, and many physicians feel that it does not make taking on new patients who may have complex, unmet healthcare needs worthwhile. Patients presently on Medicaid have difficulty finding primary physicians willing to see them. It is unlikely that making more people eligible for Medicaid is going to improve that situation. And this is only addressing payment for the clinical visit. Will there really be adequate compensation for time spent responding to patient emails, data collection and reporting, reviewing records from other healthcare providers and coordinating care?
As I mentioned above, I practice with a group of family physicians in a freestanding, non-hospital-affiliated practice combining primary care and urgent care. We are open extended hours seven days per week and all holidays except Christmas. We offer appointments for routine primary care visits, and we also see anyone who walks in during all hours of operation. We have an electronic health record (EHR) and are doing our best to track and report pay-for-performance data as required. We also strive to practice high-quality, evidence-based medicine and have an active peer review process. Sort of sounds like a medical home, doesn't it?
Our overhead costs have climbed in the past few years because we have had to hire additional staff to handle referrals, data and the paperwork load of modern healthcare. Our wait times escalated for the first year after we implemented our EHR. Although stable now, they have never returned to pre-computer efficiency. We do not see Medicaid patients because we cannot afford to. Even with good commercial contracts and a well-educated, middle-class patient population, the physicians are making less income now than they were 10 years ago. More importantly, the docs are tired and frustrated by a system that demands more for less reimbursement.
Anyone who has any understanding of healthcare delivery in the United States will argue that ours is a broken and unsustainable system. The PCMH model could be a good way to manage the care for many patients and has worked well in large organizations with the resources and infrastructure to provide the care coordination and ancillary services required. I'm just not sure that there are enough physicians or resources to make it the solution for our country as a whole.