Practices Considering PCMH Model Must Consider Challenges

Physicians looking to stay independent face some tough challenges in the current healthcare environment. How can medical practices possibly increase revenue and meet current healthcare benchmarks without being part of a larger healthcare system?

One approach enjoying expanded traffic is the Patient-Centered Medical Home (PCMH). Although physicians may have heard of a PCMH, few understand exactly what it is or the commitment involved. For my clients exploring this option, they have quickly discovered that the model, while appealing, can be overwhelming, and the ill-prepared will certainly regret their involvement.

A PCMH is a collaborative-based healthcare delivery model (generally led by a primary-care physician) providing comprehensive and coordinated healthcare to its patients. Physicians acting as a PCMH are responsible for working with the patient and other healthcare providers (both physicians and nonphysicians) to coordinate and manage a patient’s overall care and treatment.

While the PCMH model arguably promotes better patient care, it often is attractive to physicians as a way to increase revenue through a myriad of available financial incentives for participation. The financial appeal, however, can blind physicians to the burdens of PCMH participation, which can often outweigh the benefits.

To be a PCMH, practices must expend significant time and expense, neither of which are readily available in many primary-care practices. The PCMH model requires physicians to meet several objective criteria in order to participate and receive any financial incentives. These criteria include broadly:

1. Access and communication;
2. Patient tracking and registry functions;
3. Care management;
4. Patient self-management support;
5. Electronic prescribing;
6. Test tracking;
7. Referral tracking;
8. Performance reporting and improvement; and
9. Advanced electronic communication.

Each broad participation category typically includes 10 to 20 sub-benchmarks. For example, “advanced electronic communication” may include real-time EHR access; an established patient e-mail communication program; and 24-hour patient access. “Patient self-management support” may require physicians to remain informed about available community resources to support patients not only in treating illness, but also successfully manage activities of daily living. “Test tracking,” “referral tracking,” and “care management” may require physicians to monitor all patient testing and treatment across multiple providers, as well as discuss the necessity and scope of such services with patients and these providers on an ongoing basis.

While the above criteria may improve care collaboration, the mandates also tax available resources of many solo and smaller primary-care practices, which often find themselves without enough time to care for patients with scheduled appointments or lacking existing resources to meet all PCMH criteria.

Some physician practices will need to hire additional staff to meet the management and administrative demands of PCMH operations, an expense that must be factored into any review of the PCMH opportunity. Additionally, IT infrastructure and maintenance is expensive and requires a continued financial commitment to support and upgrade such resources when necessary.

A small practice or solo practitioner may not have the resources available to establish the type of electronic network necessary to fulfill PCMH technology and access requirements, and this is a hurdle that practices should appreciate in evaluating the appeal of the PCMH model. Geographic limitations may also be at issue since a rural practice without adequate local specialists, non-physician healthcare providers, or supportive community resources may find it difficult to meet collaborative care standards.

Practices that participate in a PCMH without the ability to maintain enrollment benchmarks may face future challenges as the PCMH model becomes more common and important to payers.

Participating in a PCMH without adequate resources may discourage the physician from participating in a subsequent PCMH out of frustration; deprive patients of the full benefits of PCMH participation; or limit opportunities to participate in additional models, as payers may express concern that that the practice also will be unable to meet similar program requirements.

While the financial incentives and benefits of collaborative care are appealing to the industrious primary-care physician, planning and analysis of a practice’s reasonable capabilities are critical to achieving financial success and improved patient outcomes in a PCMH model. Before your practice opts to participate in a PCMH model, make sure you talk with financial and operational advisors who can better assess your practice’s ability to meet the PCMH requirements.  If the model does not work for your practice, there are other viable options that may be a better fit. An experienced healthcare advisor can help you develop some options that may be better suited to your practice’s needs and capabilities.