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Why I have Serious Doubts about the PCMH Model


I hate to think that medicine will become like a cookbook, because there are so many things that just don’t fit inside the box.

My practice is part of a large multispecialty medical group which is currently in the process of becoming certified as a Patient-Centered-Medical Home (PCMH).  I have my doubts whether this is really going to improve patient care.

Intellectually I understand that the intent of PCMH is to provide more uniform care for patients.  There are definitely practices that do not practice the highest quality medicine and possibly this is the rationale for instituting PCMH standards. 

In 25 years of practicing pediatrics, however, I have learned to never say “always.” Things that work for one patient or family or practice, don’t always universally work for another patient or family or practice.

My biggest annoyance with the PCMH initiative is the “huddle” that is supposed to happen with all clinical staff every morning.  This is where everyone is supposed to get together to review the schedules, making notes of what each patient is going to require and what deficiencies (such as vaccines or lab work) need correcting. 

In our case, we have to use printed schedules during huddles because it is ridiculously onerous to access everything within the EHR.  These printed schedules have to be included in notebooks for each provider, so we are back to paper again! 

We are also so busy in the morning that the whole group huddle isn’t possible, especially because not everyone starts the day at the same time.  In our practice, we have always reviewed our schedules and we know many of our patients well.  I just don’t see that this procedure is going to really improve patient care.  It seems more like busy work to me.

In pediatrics, the conditions designated as chronic are Asthma, ADHD, Bronchiolitis, and children with complex medical conditions.  The exact way we deal with these patients won’t change much under the PCMH model, but the documentation must be more extensive.  And, the documentation must be entered in such a way that it can be “data mined.”

Perhaps it is a good thing for us to check that everyone in our group is consistent in how we approach each of these diagnoses.  Perhaps it is a bad thing because the government and insurance carriers will be doing the same in order to determine our pay rate!  Will they ultimately have greater authority than just reimbursement such as suspending licenses?  Just sayin’.

Currently, we do not have an active patient portal but I can assure you that all the pediatric groups in our medical group are terrified of portals!  We are concerned that parents will assume the portal acts like an e-mail or text message. 

What if they send a portal message about an emergency rather than try to call us or even just go to the ER?  In my experience, it doesn’t matter how many warnings you have in place, there are going to be some parents that just won’t pay attention to the warnings (or are too frantic or frightened to notice them).  I do hope I am wrong about this since we are mandated to have a portal.

When we are certified as a PCMH, our payments by the insurance carriers should increase substantially.  Ultimately, not being a PCMH will likely result in fines and reduced payments for all medical practices eventually. 

I think what bothers me the most is having medical care dictated by government and insurance bureaucrats.  And, I fear that soon we will all have to follow established guidelines or not be paid for our services. Worse yet, it is possible that there will be even more dire penalties for failing to comply with such guidelines, like being sanctioned or losing our license to practice medicine.  I hate to think that medicine will become like a cookbook, because there are so many things that just don’t fit inside the box.

Perhaps I am lucky to work in a practice that attends to the needs of our patients in a thorough and complete way, so I mostly see the extra steps associated with the PCMH as adding extra unnecessary work to everyone in the office.  Perhaps there are practices that really need this level of improvement. And I’m sure that there are things that need to improve in ours.  But I do resent being told how to do my job by nonmedical entities.

I’m glad I’m nearing retirement age rather than just starting out in my career with all the burdensome requirements that we must now adhere to.  I’m worried that medicine may become so “paperwork” overloaded that no one will want to go into the field.  That would be a disastrous outcome for well-intentioned measures.

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