The PCMH Parade


The AAFP loves to put their winners in the limelight and they did it again recently when they paraded out some docs from Rhode Island. These physicians jumped into a PCMH (patient centered medical home) pilot project “thanks in part to financial and technical support from public and private entities”. Never hurts to use other people’s money, I guess.  Anyway, they hired a care manager and trained existing staff to take on additional care tasks” (which I am sure they loved) and the docs proclaimed that this the model can succeed!

Here is how it happened.

  • Rhode Island had an initiative which “began in 2008 as a pilot project involving just five practice sites and is slated to become a nonprofit with a new name, the Care Transformation Collaborative of Rhode Island, in June. About 300 primary care physicians participate in the initiative, which now includes 73 sites and covers an estimated 320,000 patients. The goal is to reach 500,000 patients in the next three years.” (Hmmm, 300 primary care docs divided by 320,000 patients.   That’s a about a 1000 patients per doc.  More than half of a normal doctor’s panel of patients.)
  • Under the program range the docs were paid from $6.50 to $8.75 per patient based on quality performance. Let’s use an average of $7.50.  That would bring in $96,000 a year.  “Participants in the program are expected to use the monthly payments to cover overhead during the transition and to build a sustainable infrastructure, not as a revenue supplement.”  (That’s right.  That money is just for staff.  I guess you are supposed to do this for free.)
  • Practices submit performance data quarterly, and if they don’t meet performance targets, they don’t get bonuses. (Once again, quality metrics have not been proven to improve care but who cares about evidence? )

So what were the conclusions?

  • Overall, fee-for-service still constitutes more than 90 percent of practice revenue, Hurwitz said. She acknowledged that fee-for-service is unlikely to drop to zero in any care delivery model but said it could be reduced substantially by combining a value-based payment with an infrastructure payment and other incentive payments.

The one thing that I have found researching direct primary care, before I jumped in, is that docs who do hybrid models and dabble with both monthly payments and insurance fee-for-service usually fail miserably.  This whole story has more holes in it than swiss cheese.  All this work for 10% of your practice and you are beholden to unproven metrics and begging for grants?  If you read the rest of the article you will see how hard they are trying to convince themselves this is a good thing.  What a joke.




Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  5 comments for “The PCMH Parade

  1. Steve O'
    January 24, 2015 at 3:27 pm

    The overarching plan is to convert healthcare from a professional SERVICE to a retail PRODUCT within ten years. DPC treats medical care as a professional service, and depends on the ability of the patient to “establish metrics regarding service delivery.” Such metrics tend to be rather harsh and arbitrary – “Hey doc – you’re fired.”
    Of course, letting the rubes establish their own measures terrify the arrogant and sub-par practitioners in Ivory Towers. The Leadership sees itself as though they are Regional Directors at Corporate, looking at worthless numbers and belting out irrelevant commands to the clerks who actually deliver the care. Such is the new revolution in healthcare – “May I take your order? Do you want fries with that?” I’m sure they will have the doctors coming into the waiting room as greeters, and maybe even out waving the signs “No wait now in clinic!” if their schedule has an unexpected no-show. Like they do at Jiffy-Lube.
    And that’s the stark balance of the future – DPC vs. McMedicine. The winner won’t be the side with the most satisfied patients, but the most K-Street lobbyists on their payroll. Sigh.

  2. Steve O'
    January 24, 2015 at 2:40 pm

    Pat, so’s the “intermediate caregivers” on the team can swoop in and snatch the glory of doing the doctor’s job and wearing a white coat. Just because they call it “glorious” don’t mean it’s so.
    We have Dr. PA’s and Dr. PharmD’s in our Client-Centered-Clubhouse, and they help guide and direct my treatment. I can’t get a non-formulary approved; but one of them gave a patient “the constipation shot” — I’m still looking through Harrison’s for THAT one. (Since the PharmD’s oversee the approval process, they auto-approve their own prescriptions.)
    Much more glory awaits us. And just cause you call it a “honey-bucket” doesn’t mean there’s much honey in there….

  3. RWatkins
    January 24, 2015 at 10:57 am

    It’s striking that the countless hours the docs put into building these grotesque PCMHs is never counted as overhead – the assumption is that they do this work for free.

    But, hey, they taught the MAs how to do worthless monofilament exams on diabetics!

    • Steve O'
      January 24, 2015 at 9:45 pm

      Yes, we are heading backwards in time. You mentioned the worthless monofilament examinations – I do not dispute that. In Physical Examinations, we were taught to recognize quite a few obsolete findings that we’d never see outside of the Third World – e.g. Quincke’s Sign for AI. Those came from a day when diseases could not be interrupted from their natural courses – the physician could only chronicle the manifestations of the inexorable progression of disease. We do not see Quincke’s sign in America – an incompetent valve is replaced far before such findings manifest.
      But in the New Medicine, with the handling of diseases handed off to the incompetents who cluster about the Client-Centered-Clubhouse, the principle has shifted back to observing and documenting the ravages of disease, not struggling to oppose it. Yes, we will have the diabetics with the monofilament map quickly racing back from the toes – the creatinine climbing – the neovascularized retinas failing. The New Doctors will diligently enter these findings in the EMR. That is what happened with most diseases, a few hundred years ago, recording their natural progression. Our recent medical arrogance of the last fifty or a hundred years or so – the principle of combatting disease – will be forgotten, and medicine will go back to the Dark Ages of diligently recording and notating the “natural process of disease.”
      That was medicine of the Dark Ages; and is still the medicine of the darkest parts of the Third World. And it is coming to a Clinic-Centered-Clubhouse near you!

  4. Pat
    January 24, 2015 at 9:35 am

    Under this Byzantine mess, where is the physician’s incentive to do all this extra garbage? What is the incentive to “cover overhead during the transition and to build a sustainable infrastructure”? It’s not like the doc will be able to later sell any of this practice he helped build, and there is no extra salary bonus along the way, so…why?

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