Beauty Health for Life

Nice medical home laptop, but how do I feel about it?

Over the years, the Disease Management Care Blog has repeatedly reminded the spouse of her particularly good fortune in marriage. Her lingering skepticism, however, has prompted the DMCB to amass further evidence of her marital bliss by

a) asking other spouses in similar relationships if they feel as fortunate and, if so,

b) collecting data about the DMCB-like personality traits in their husbands.

Bonhomie? Check.

Willingness to share the TV remote? Check.

Cooking the occasional meal at great personal sacrifice? Check.

Announcing how good that meal is? Check.

Yet, when confronted with the indisputable statistical associations that correlate nuptial happiness and DMCB"ness," the spouse has remained stubbornly unmoved. At the spouses pointed request, the DMCB is rechecking the math.

Readers will probably also remain unmoved about this publication that uses a similar approach to examining the impact of the Patient Centered Medical Home (PCMH) on clinic staff morale, satisfaction and burnout. Sara Lewis and colleagues surveyed the staff of 65 "safety net" clinics participating in a "5 Year Safety Net Medical Home Initiative" that had been co-funded by the Commonwealth Fund.

At the time of the survey, the 65 clinics were in the process of implementing becoming PCMHs but had not yet attained that status. The authors used a Likert-style survey to assess PCMH-"like" attributes among these non-PCMH clinics, such as patient access, data tracking, care management and quality improvement.  The survey also asked about staff morale, satisfaction and burnout.  The authors then correlated whether individual scores or a total roll-up score of all the PCMH-like attributes correlated with better clinic morale, higher satisfaction and less burn out.

There were 773 providers and staff members and 603 (78%) responded. 33% rated morale as good, 54% rated job satisfaction as very good and 40% had some burnout.  Based on an analysis of odds ratios, some features of a PCMH - particularly quality improvement - resulted in up to a three fold improvement in the three measures. However, while the total PCMH score was associated with better morale, it looked like there was also a greater association with worse burn-out, which had a statistically significant lower odds ratio of .48.

The DMCB finds these up and down results about the PCMH in nonPCMH clinics unconvincing.  It believes the attributes of a PCMH, if carried out as envisioned, should add up to more than the sum of its parts.  While some of the parts that are outside of a medical home seem, according to this paper, to correlate with morale, satisfaction and burnout, this gives little insight on how medical staff would really react to the transformation of a primary care clinic.  By the way, this is not the first time a PCMH-"like: methodology has been used, which makes the DMCB wonder if fully functioning PCMHs are less common than we think.

What is striking, however, are the basic measures of morale, stress and burnout. Based on these data, it would appear that these safety net clinics have some serious staff issues with 67% not having good morale, 46% not having good job satisfaction and just under half having burn out.

More evidence of primary cares travails says the DMCB.

The good news is that the DMCB remains optimistic that the math will eventually bring the DMCB spouse around.  Maybe the enthusiasm - and the math - about the PCMH will similarly prevail someday.  Until then, this papers approach doesnt lend much insight about the real potential of the PCMH. Last but not least, if these 65 clinics are representative of primary care morale, satisfaction and burnout in general, the DMCB far less optimistic about their future with or without the PCMH.

HOW much for the PCMH?!*

According to Drs. Gill and Bagley, writing in the Annals of Family Medicine, the costs of transforming a primary care practice to a Patient Centered Medical Home should be generously borne by "payers."

While wishful thinking about payers deep pockets is not new, the article has some eye-opening data (with Disease Management Care Blog provided links) on just how much some or all of the elements of a PCMH cost:

a) $1850 per month per practice or $17,000 per physician,

b) $5,600 start-up then $2,200 per year related to the costs of reporting outcomes,

c) $117,000 per physician per year, and

d) up to approximately $15,000 per practice per year for a management facilitator. 

No wonder the DMCBs friends in academia want someone else to pay for it.

In the meantime, companies like this continue to offer a different business model. Instead of rebuilding and equipping an entire primary care practice for a croup-to-guts "transformation," population health (definition here) service providers focus on those patients who are at highest risk and provide a modular combination of in as well as outsourced services. While there is no head-to-head cost comparison of PH vs. PCMH, it would appear that the per patient approach of PH has a competitive pricing advantage.

Stocking up for allergy season

And speaking of outsourced services, the DMCB joins its other colleagues in looking forward to EHRs "meaningful use" criteria go from being meaningless to being truly meaningful.

For an under-recognized example of just how meaningful things will become, check out this interesting blog posting that describes the use of cloud-based EHR-data to follow U.S. allergy statistics.

While the information is interesting on its own merits, think how these data could be used by savvy providers to match allergy "market demand" by "stocking" a "just-in-time" "inventory" of allergy-care services such as patient reminder campaigns (for those with allergy-provoked asthma, "be sure to use your peak flow meter!") extra condition-specific appointments ("your provider with allergy expertise can see you this morning!"), treatments slots (nebulizers and immunotherapy ready to go) and medications (OTCs and prescription meds for the in-house pharmacy).


*Image from Wikipedia