A Bleak Prognosis for the Patient-Centered Medical Home

For years, experts have sounded the alarm about the crisis in primary care—the shortage of doctors, the lack of incentives, the upside-down payment structures that offer the least to the doctors who do the most. The advent of alternate payment models, and in particular CMS’ creation of Comprehensive Primary Care Plus in 2011, tried to turn the tide by rewarding those practices that did things the right way.

But as Edward Bujold, MD, writes in a heartfelt and disturbing essay in JAMA Internal Medicine, “The Impending Death of the Patient-Centered Medical Home,”¹ value-based care is in deep trouble, at least in some places. Bujold has spent 17 years trying to make the patient-centered medical home (PCMH) model work in western North Carolina, and an 80% reduction in hospital admission would suggest he’s succeeded. Instead of being rewarded, however, he’s mostly seen a loss of revenue from all fronts: Medicaid cuts, more self-pay patients, and, of course, declining revenue from hospital patients he no longer sees. Hospitals, he writes, are gobbling up practices and increasing patient out-of-pocket costs.

“My practice is in the process of reviewing all our expenses to reset our expectations, and part of this task may be to realize we have to dismantle part or all of our PCMH,” Bujold writes. Medicaid stopped funding the embedded PharmD, and overhead has becoming a rising share of costs without that hospital revenue.

The hard part, he feels, is that area payers are benefitting from the practice’s efforts but not supporting the cause. “At present, there is little incentive within North Carolina to continue the PCMH process except that it is the right thing to do,” he writes.

One could ask whether Bujold’s case is isolated. But that question is answered when an accompanying editorial comes from Laura L. Sessums, JD, MD, and Patrick H. Conway, MD, MSc, who were both at CMS at the time of submission. In “Saving Primary Care,”² Sessums and Conway write that for team-based primary care of a population to be sustained, the money must follow. However, payments have varied widely by geography. Compared with North Carolina, they write, “Rhode Island required that all payers increase the percent of total medical dollars for fully insured members paid to primary care by 1% annually from 2010 to 2014, and then sustain that increased percentage.”

Sessums and Conway go on to explain the possibilities under Medicare’s Comprehensive Primary Care Plus model, but as Bujold notes, the real need is for the commercial payers to get on board—and for typical patients to be able to find coverage they can afford. The challenge with the PCMH model is that it demands that commercial payers cover some of those overhead costs for those practices that find the secret sauce of keeping people out of the hospital.

“A single practice, as Bujold found, is unlikely to change the payment and care delivery landscape in a state all by itself,” Sessums and Conway write. When payers and practices collaborate, however, much is possible.

Conway will have the chance to put his words into practice. On October 1, 2017, he will become the new president and CEO of Blue Cross Blue Shield of North Carolina, the only insurer scheduled to offer plans on the exchange in all the state’s counties.

References

1. Bujold E. The impending death of the patient-centered medical home [published online September 25, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4651.

2. Sessums LL, Conway PH. Saving primary care [published online September 25, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4991.