The three-legged stool of PCMH

I have the unique opportunity to speak with many physicians as I travel around the country. A physician recently commented that Primary Care physicians are potentially putting themselves out of business promoting a model of care that relies on non-physicians to varying degrees. This comment solidified the fact that primary care transformation must be total transformation and not partial by implementing only some components of PCMH such as care coordination without a concurrent focus on comprehensive care. There is a great focus nationally on coordination of care. There is also a tremendous amount of money being directed toward Health Information Technology. Those two components while very important are only two legs of the three legged stool on which PCMH and the future of primary care rests. The third leg is comprehensive care. Without a balanced focus on comprehensive care by primary care physicians, the PCMH concept will not create enhanced value just on care coordination and HIT. Indeed, primary care will be "giving away the farm" by not emphasizing the importance of comprehensive care while delegating care coordination when appropriate.

A significant amount of care coordination can (and should) be done by non-physicians. That is all part of creating a team based, patient centered, high-performing practice. The goal is to free up physicians to be "comprehensivists" and not care coordinators. Physicians need to do what they spent at least 7 years of their life learning to do. This is the critical third leg of the 3 legged stool. All too often I see primary care practices that have become more like urgent care centers or specialty referral centers. This is a greater challenge in metropolitan areas than rural areas where by necessity care is more comprehensive. Primary care physicians are quite capable to manage the diabetic or stable angina patient. We are trained to manage most acute illness and injury including non-surgical orthopedic injuries. We are also trained to perform most minor dermatologic procedures and many testing procedures. If practices continue to delegate the comprehensive care and management that they are best positioned to provide, then indeed also delegating care coordination may create vulnerability for some practices. Primary care practices must remember that they are not only capable to provide chronic care, but they are the most capable and qualified by having a continuous, whole-person relationship with the patient.

While much of care coordination can indeed be done by non-physicians in an office, there is one aspect that must be managed by the physician. TransforMED strongly encourages practices to have formal written agreements with the specialists they refer to. This document needs to stipulate that the primary care practice will have all relevant information to the specialist office ahead of the appointment. The primary care practice also stipulates that the patient is fully informed as to the reason for the referral and what the expectations or goals of the referral are. More importantly, the document clearly stipulates that referrals are for consultation not ongoing management unless otherwise stipulated. It also clearly outlines that expensive imaging should be discussed with the primary care provider before ordering and any other referrals are coordinated through the primary care office. This will empower primary care physicians to reduce redundant testing, unnecessary or redundant referrals and unnecessary procedures. Some health insurance companies are now providing primary care physicians with data on specialty physicians in their market on quality and efficiency so that the primary care physicians can make the best referrals possible for their patients. This information has been quite enlightening to some physicians. While we often talk about the specialists we refer to, it is interesting how often primary care physicians do not think specifically about the hospitalists they refer to. All of the same rules should apply around information, care transition and efficiency. Primary care physicians who do not do hospital care themselves must choose hospitalists that are skilled enough to manage most of the patient's needs themselves and not just be consult coordinators. Only physicians can negotiate with other physicians to insure high quality and efficient care for their patients. That is the physician component of care coordination. We are not delegating all of care coordination, we are delegating what does not need a physician's time and skill.

I have stated many times that this is a critical time for primary care with unique opportunities and vulnerabilities we have not seen before. Primary care must empower itself now. No one will do it for us. That empowerment must be by providing comprehensive care, insuring care is coordinated for our population of patients and being the leaders in the HIT implementation. One could say that standing on this three-legged stool will allow primary care to reach new heights.

The question is often what can physicians do to get started on the path of becoming a patient centered, high-performing practice. Total practice transformation is difficult and while it needs to be the ultimate goal, there are things that physicians can do that will make a dramatic difference. Physicians need to start thinking in terms of a team with members of the team managing much of care coordination and minor illnesses. As one goes through their day the question should be: "Did I need to do that and could someone have done it better?" Designate a care coordinator for the patients in a practice. Begin to learn about the opportunities and advantages of Health Information Technology for our practices. Download the sample specialist agreement from the Practice Forms and Templates Zone within Delta-Exchange and have meaningful discussions with the physicians you refer to. This has to only be done once, not with every referral. Never refer to "doctor on call" or a specialty group in general. Identify those specialists that are best for your patients and your practices. Immediately stop referring medical management opportunities that primary care physicians are better positioned to do. Physicians will now have the time if appropriate teams are in place. Stop referring non-surgical cases (most back pain) to surgical specialists. Refer to surgeons when surgery is needed. Refer to proceduralists when procedures are needed. Only refer to hospitalists that actually take care of the majority of in hospital needs of your patients and make sure they are part of the PCMH team and all that implies.

The PCMH movement has given primary care the opportunity to redefine itself in the healthcare system. It can be done very quickly in calculated, incremental steps. Indeed it must be done very quickly. It can start with the next patient you see right after reading this article. It doesn't have to cost a penny and indeed may increase revenue. It has to do with understanding the big picture, the opportunities and the vulnerabilities. It is recognizing that the stool must have 3 legs to reach new heights. It is recognizing that the key is not "giving away the farm", but transforming the "farm" to meet the needs of our patients in the 21st century.