When I was a much younger man, I had a 1968 Chevy Impala. I loved its V-8 engine and spaciousness, but I paid a steep price for it. It consumed gas like a drunk on a binge. It was prone to break downs, usually in the left lane of a busy highway. Even as it consumed my limited financial resources, I couldn't count on it to reliably get me to where I wanted to be. Yet I held onto it. One day, though, its transmission gave out, and I finally had to resign myself to buying a new, more reliable, more modern, and efficient vehicle. Yet to this day, I miss my clunker.
I am reminded of this when I think about the state of primary care today. Many of us are attached to a traditional primary care model that may no longer be economically viable - for physicians, for patients, and for purchasers.
We hold onto a model where primary care doctors are paid based on the volume of visits, not the quality and value of care rendered. We hold onto a model where patient records are maintained in paper charts in voluminous file folders, instead of digitalizing and connecting patient records. We hold onto a model that generates enormous overhead costs for struggling physician-owners but generates insufficient revenue. We hold onto a model that most young doctors won't buy, as they pursue more financially viable specialties and practices. Most of the time, traditional primary care still gets patients to where they want to be - high quality, accessible, and affordable care. But like my Impala, traditional primary care is at constant risk of breaking down, as established primary care doctors close their practices, leaving their patients without a regular and reliable source of care.
Most of us are unwilling to trade in the brand we know, even as we are told that there are better models of primary care in production.
Now, I know that some readers of this blog will be offended by my comparing traditional primary care to a gas-consuming clunker. Let me be absolutely clear: I have an enormous appreciation and respect for the work being done by the hundreds of thousands of primary care physicians in "traditional" practices. They work long and hard to provide their patients with the best care possible, even as the system seems stacked against them. But I believe that the traditional primary care is not sustainable, at least not for the long haul. We may be tempted to keep pouring more money into it, but at some point, we will need to face facts and trade it in for a better, more reliable, more modern and more efficient model of primary care delivery - the Patient-Centered Medical Home (PCMH).
The PCMH is no longer just a theoretical blueprint that is years from going into production. Instead, physicians and patients are taking it for a test drive in the dozens of communities across the country that have launched PCMH demos. Federal and state governments, private insurers, and businesses collectively are putting billions of dollars into developing and assessing the PCMH model. The early returns are promising, according to an analysis by the Patient-Centered Primary Care Collaborative. And the new health reform legislation includes funding for PCMHs under Medicare and Medicaid, for community-based programs to help primary care physicians restructure their practices as model homes, to develop PCMH curricula in medical education, and to encourage adoption by Medicare Advantage plans and by qualified private insurers.
Yesterday, the federal Agency for Healthcare Research and Quality (AHRQ) announced the launch of the Patient Centered Medical Home website "devoted to providing objective information to policymakers and researchers on the medical home, www.pcmh.ahrq.gov ... the site provides users with searchable access to a rich database of publications and other resources on the medical home and exclusive access to AHRQ-funded white papers focused on critical medical home issues."
Physicians now have an opportunity now to test drive the PCMH, by doing their own practice assessment, using ACP's Medical Home Builder; by participating in demonstration projects in their own communities, and by learning more about it from the PCPCC, AHRQ, and from ACP.
There comes a time when a beloved old stand-by must be replaced by a newer and better model. I still fondly remember my '68 Impala, but you couldn't get me behind the wheel of one now. Primary care needs to consider if now is the time for it to trade in traditional primary care for new ways of organizing, financing, and delivering patient-centered primary care around the PCMH model.
Today's question: Is it time to trade in traditional primary care for the PCMH?