My nose wriggled as it often does when I smell something unusual, but with all this talk about Patient Centered Medical Homes (PCMH), I wanted to explore the concept and do some investigating of my own. Soon after embarking on this venture, while just trying to find a simple definition of the concept, I was rendered somewhat impotent; as with many aspects of the Affordable Care Act, there simply is no easy explanation. What I kept stumbling upon were varying derivatives of qualities such as a “team based model of care led by the patient’s personal physician.” Alternately, there was a lot of language peppered with words such as “comprehensive” and “coordinated” healthcare. We know that the Patient Protection and the Affordable Care Act espouse PCMH as the model that practices ought to strive to become, and if they are successful, they may become eligible to reap the rewards of financial incentives offered through the ACA.  The Agency of Healthcare and Quality Research ( AHQR) , a subdivision of the Department of Health and Human Services, provides 5 tenets that must be present in a PCMH:

• Comprehensive Care: The practice or healthcare facility must be responsible to accommodate the large majority of their patients’ medical and mental healthcare needs, including prevention and wellness to acute and chronic care. They are tasked with having those tough conversations about end of life issues for patients in the practice with terminal illnesses that need to have resuscitation issues addressed and documents signed to make their end of life wishes known.
• Patient-Centered: The practice must provide healthcare that is relationship based and takes into accounts for the entire patient as a whole.
• Coordinated Care: The PCMH is accountable to coordinate all elements of patient care within the broader healthcare system.
• Accessible services: Practices must be able to provide for shortened wait times for urgent care services. This may require hiring a mid-level practioner, such as a nurse practioner or a physician assistant, to facilitate this function. Patients must have access to a member of the healthcare team via some modality, phone, or electronic messaging at all times.
• Quality and Safety: The practice must abide by evidence–based medical practice to guide in the clinical decision making processes. These best practices are to be followed and serve as the foundation for all clinical decisions.

These practices sound very good on paper and certainly may serve as the goal many would be in agreeance to govern medical practice in an ideal world. However, one can also see how the adoption of such principles into your practice, in a measurable and meaningful way, could result in a lot of additional expense, such as the recruitment and payment of additional staff.

Technical issues, such as updating or changing EHR software and potentially vendors, may also be required. Older facilities may require structural upgrades to the facility to make room to accommodate additional staff. In a summary statement delivered by Secretary of the Department of Health and Human Services, Sylvia Burwell, a $35.7 million dollar investment was given to various medical practices and hospitals from congressionally approved ACA funds. These funds were to cover the construction and renovation to some 147 practices sites and community health centers that had embraced the model of patient centered medical homes.

The need is far beyond the brick and mortar considerations of implementing a PCMH; there are staffing and technology considerations as well. Michael K Magill MD, of the University of Utah School of Medicine, has conducted research that involved the interviewing of hundreds of medical directors, nursing supervisors, and medical practice managers to best figure the cost of implementation of a PCMH in addressing the additional staffing hours and the types of professionals required (nurses, physician assistants, physicians). He then created a tool to factor in all of these components and quickly calculate costs. The equation was established to determine how much the implementation of the PCMH model might cost a practice annually. He estimated the cost to be $105,000 per physician in the practice per year in order to fulfill the requirements as set forth and in accordance with the National Committee for Quality Assurance. In calculating cost, for example in a practice of 5 physicians each with a panel of patients, the costs would amount to an additional $550,000/year to become a PCMH. These are all upfront costs.

These are significant upfront expenditures, and a practice is not assured in advance of receiving any additional reimbursement. In fact, it is noted on the AHQR website that while many of the propositions involved in implementation of the PCMH are included, they are not necessarily “currently funded” due federal budget constraints. Funding may be submitted for approval, but it may take an act of Congress, literally, to receive the funding. These figures leave those smaller practices that survived the 2009 EHR mandate and the newly rolled out ICD-10 mandate perhaps unable to survive if they wish to come into compliance and become a designated PCMH.

The path to becoming a PCMH is ridden with red tape, and after reviewing the Agency for Healthcare Quality and Research ( AHQR) guidebook, it  is soon apparent the task is a daunting one —  a far too daunting a task for many physician practices who had initially prepared to adopt the concept, in good faith.

One may quickly become quite wrought with frustration. For example, there are webinars and resource websites  that highly recommend practices hire a “practice facilitator” to guide them. The manual further delineates the core competencies one should look for in a “practice facilitator” in Chapter 4. Almost immediately in Chapter 5, it describes how you or a designated person within your practice will train them. Did you catch that? Yes, you read correctly. It is the physician’s responsibility to train the person he or she hired to facilitate the transformation to train them on their job. So again, the physicians shoulder the responsibility, even when they have hired a professional to guide them in their implementation and transformation of the practice to become a patient centered medical home.

As stated, somewhat tongue in cheek, by Robert Morrow MD, a private practice family physician and clinical associate professor at the Albert Einstein School of Medicine, “Just like with any home, someone’s got to pay the rent.”