The challenge for the PCMH


Category : Medical Rants

Bob Doherty wrote an excellent article about the problem of funding the PCMH – When will insurers really do something real to save primary care?

This good doctor is absolutely right—“absent public or private funding for the medical home [it] is just not going to happen.”

In my view, it is a damning indictment of the health insurance industry that even though this physician’s practice has re-engineered its workflows, invested heavily in information technology, achieved benchmark levels of quality and service, and won NCQA certification as a PCMH—everything that primary care practice are being asked to do by payers!–not a single one of them has stepped up to underwrite the investment. This, despite the fact that dozens of health insurers are listed as members of the Patient-Centered Primary Care Collaborative, a coalition of “major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home.” (ACP is a founding member of the Collaborative and sits on its governing board.)

Now, I anticipate that health insurers will cry foul about my blanket indictment of their lack of support for primary care practices. They will, with some legitimacy, point to the 27 multi-payer pilots in 18 states that are being supported, at least in part, by health insurers. I wonder, though, how many of those pilots are paying the practices anything close to what it really will take to restore primary care as a viable practice model and to reduce the inequities in primary care compensation compared to other specialists. Not many, I expect.

Bob and I are getting closer to agreement all the time.  We both understand the importance of primary care.  We both understand that excellent primary care will require new funding.  We would love for the PCMH to work, but we despair at the lack of funding.

I want more understanding of the retainer model, because I remain skeptical about insurance companies.  I have no skepticism about patients.  If we develop the proper models, patients will pay for excellent primary care.  The high priced retainer model can be modified to a payment system that is more similar to our monthly cable bill, or cell phone bill.  Do we not think that excellent primary care is as valuable as a cell phone or cable TV?

Comments (4)

While I agree with your sentiment, I think we should look at dismantling policies that support the current system of payment, rather than trying to create a system of payment to support what we think is good medical care (which is what PCMH is).  This is a suble difference.  The role of government should be to allow individual patients to pursue medical care from providers of their choice, while allowing a payment structure that supports patient-physician relationships and helps the needy. It should not be trying to determine what is good care and how that care should be delivered nor trying to give care to everybody.  The more physicians and patients look to the government to solve the problem, the more likely we will get mired in bureaucracy. We should realize that it is three big players- government, insurance, and pharmaceuticals- that created this mess.  They are all acting rationally, in their best interest, and believe that they are helping the American people.  And the government is still obsessed with making physicians accountable for public health measures that reflect poor lifestyle choices rather than poor medical care.
I think indepedent medical practices (aka retainer medicine) will be important, but I've yet to see a real proposal on how 1) this could be expanded to most Americans, and 2) it would deal with inpatient medicine, urgent.emergent medicine, and medical procedures and 3) deal with expensive chronic disease (think MS, SLE, etc).  Until serious thinkers offer such proposals to these problems, indepedent medical practices will only attract patients with expendable income with good insurances in large urban areas.
By the way, primary care is already under a monthly payment system similar to a monthly cable bill.  It is called a withholding on your biweekly or monthy pay check.

I practice in a full PCMH.. It works well for us. We are Group Health Cooperative, based in Washington state and northern Idaho(1400 Practitioners).  We have reduced costs, improved outcomes and made our physicians more satisfied.  It is a no brainer to do this if you are an insurance company. But you actually have to do the work of transforming how you practice.. Traditional insurance companies have no capacity to actually make the transformation happen. They dont have a known mechanism to transfer the savings back to the primary care sector, or assure that real change in patient care happens.  Our company, certainly can do that. We are able to invest in things that make things better, because we all benefit.  The conventional insurance companies will almost certainly fail in this effort.
The winners will the the large integrated health systems that can organize this work.  If you want to succeed you will have to find a way to link up with one of these systems.  The idea of self employed physicians is dying out now. Young primary care docs are  mostly joining practices that are integrated. Over time the mom and pop practices that I once ran will die off unless a new business  model is discovered.. The insurance companies, have very long experience with the reality that in private practice we all were very good at " running up the charges" evey time we could.  So they cannot bring themselves to believe we will change, and they are probably right.
And by the way, our pay is good, our patient loads were reduced to make it work, and we have very good vaction cme and retirement benefits.. Also, if you are emotionally alligned with the principles of the medical home, you will have very little loss of autonomy.  I have found that my sense of freedom in the way I practice has increased compared to private practice. Being given more time per visit and the access to electronic and telephone visits to extend my ability to serve patients outside of the traditional face to face visit is wonderful.. Having clinical pharmacits and great consulting nurses that work on chronic disease management are great tools to use.  
If you develop a system of retainers external to the insurance industry to draw in patients to "botique" practices, you may have some nitch success. But ask yourself, will you be able to expand this outside of the affluent community?  Will young physicians looking for work see this as a robust system, and want to joing you?  The future of health care delivery is in the hands of the young docs and their choices. Design your systems to attract them, and you have a chance. If they see it as risky and difficult, and high maintence , it wont make much of an impact .. 
Good luck

Hi doc,
I've followed you for years and this is another great article.  I'll cut through all the extra talk and just agree with everything said above by you and ErnieG, i.e., primary care is dying for lack of a good payment system, yet is the solution to our failing system and we need to look for our own solutions.
You and ErnieG suggested you'd like to learn more about retainer practices and how they can help.  That is where I come in.  Quickly, i'm a board certified FP right out of residency and Sept 2, 2010 i started a concierge practice,  Humbly, i'd like to say that very well could be the answer for the vast majority of patients.  I offer unlimited home/work/office/technology visits for $10-100/mo based on age, all patients welcome regardless of medical history or insurance.  furthermore we offer wholesale pricing on medications, lab tests and medical supplies for pennies on the dollar (email me directly and i'd be happy to share price quotes).  ex: cholesterol panel for $3.00.  Imitrex 100mg/#9 $12.   Practically anything we can do in house is included in the monthly membership (except cosmetics) including ekg, spirometry, blood draws, urine dips, dexa scans, (xray, ultrasound, stress treadmill when we grow). 

The most successful decision we've made was to work WITH insurance brokers who were independent and able to customize the major medical plans to cut the fat.  Now, what would otherwise look like a poor quality plan is actually a very elegant and affordable plan in combination with AtlasMD.  We worked hard to insure that our prices are low enough that patients and companies still save money after adjusting their insurance and adding AtlasMD.  Working in parallel with the insurance companies insures that all the incentives are properly aligned.   We are saving young families as much as $1000/mo and small companies 30-45% on their insurance costs while IMPROVING quality and access.  Now employees LIKE the hsa style plans b/c our low costs let them keep more of their money.

After being open just 6 months, we have nearly 200 patients and are nearly 1/2 way to the profitiability mark of near 400 and full capacity will be 4-600/doctor.  We'll be adding a doc by June and looking to grow further.  We are just now starting to work with the larger ins companies b/c even they misunderstood what retainer practices could do for them and for patients.  Its rare b/c the pt's have better/cheaper care, the doctors see fewer patients and increase their income and the insurers sell more plans w/ less administrative costs.

Anyone who studies retainer practices will realize the avg cost is lower than they realize and that less than 4% of concierge patients are "executives". 

I think this style model could be the solution we're looking for but i expect competition to improve it even further.


It was obvious from the beginning that the PCMH meant more work, greater administrative burden, higher overhead, and decreased revenue. Whether it results in better patient care, beyond meeting NCQA standards, remains to be determined.
Hoping to one day become part of an insurance company's pilot project is not a good foundation on which to build a medical practice.
The actions of the primary care societies in urging/forcing on their members a financially disastrous model of patient care are so incompetent as to verge on malfeasance.

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