Thursday, September 17, 2009

Learn From Docs in the Trenches About the Patient Centered Medical Home: A Dispatch from the Front

The Disease Management Care Blog attended a masterful presentation on the Patient Centered Medical Home tonight. It was one of several sessions designed to increase physician awareness, enlist support and prepare for its eventual implementation across the State.

This was about as close to the trenches as you can get. All 30 or so family docs in the room were full time, private practice and seeing more than 30 patients a day in relatively small physician-owned clinics. The are overworked, they are cynical and they worry every minute of every day about quality and cash flow. Most had heard about the PCMH and none had implemented it. They came to listen.

The DMCB also listened and approached this like a 'focus group.' It came away with some important lessons:

1. Despite its academic merits, don't assume the PCMH is a self-evident slam dunk. These guys have seen other silver bullet solutions (like RVUs and capitation) that were also touted as transforming primary care for the better. They are skeptical and you need to posture the 'pitch' accordingly.

2. Be prepared for 'showboating.' Anybody who has been to a lot of physician meetings will recognize the phenomenon: a passionate physician in the back of the room who is loudly doubtful, asks rhetorical questions and dominates the agenda. The presenter loved him to death with upbeat answers that helped win over the rest of the crowd.

3. The presenter needs to have personally implemented a PCMH in his or her practice and report not only what the academic literature has to say, but what his/her own experience was like including the downsides. The best way to portray the PCMH is a balance of advantages and disadvantages, with the former outweighing the latter. In other words, be realistic.

4. In a variation of number 3 above, the presenter will need to not only speak to the standard principles that define the implementation of the PCMH, but be comfortable with the many local factors that influence the implementation. Examples include the lack of any RNs in many offices, a shortage of adequate square footage and the fact that electronic records typically do not include registries. Be genuine.

5. Like it or not, there is no way the PCMH can be separated from physician payment reform. The docs made it absolutely clear that this is not about getting additional payment for the PCMH, this is about a complete reorganization of payment for all services including the PCMH.

6. There are physicians out there who have done some pretty amazing things on their own. Their worry is how to retrofit what they've done into the PCMH. The presenter's job is to respond to that and agree that the implementation needs to accomodate that.

7. Finally recognize that Rome was not built in a day. The DMCB took a decidedly unscientic pre-post poll of some of the physicians and the best that could be said was that many docs moved from being skeptical to less skeptical. Winning these guys over for good is going to take a lot of work.

Other telling quotes:

Think the docs are not aware that there's something wrong? 'Thanks to the PCMH, if a patient's diabetes doesn't come under control, I'll know it's not my fault.'

On delegating: 'Tasks for the staff, decisions for physicians.'

And finally, a credible insight on the physician shortage: 'We all know docs that were going to retire, but, thanks to the markets, they can't. They have to work a few more years.'

No comments: