Accountable care can not happen without PCMH

The following was written by Paul Grundy, M.D. and is posted with his permission. Emphasis added is mine.


Accountable care can not happen without PCMH it is the only way it can work or should work. IBM , DOD, the European Union want this as the very standard of care we all want to buy. Care has to be built on a meaningful relationship. Plus why would one not want to build high quality lower cost care on the second strongest relationship to humanity - the doctor patient relationship. My employees tell me they want a real relationship, better communication, real access all part of and key to PCMH.
I do not want a hospital system saying they are an ACO when they are really a milking machine an ATM for body parts and my strongest defense for that is to insist as a buyer that the base of any ACO has and accountable relationship (PCMH is the agreed principles for that) as its very foundation. I want my patient to look their doctor (personal doctor who is willing to deliver comprehensive care) in the eye and say is this the best for me doc is it the care you would deliver to your mother.
You see when we have the tools to deliver real care coordination at the point of care the only logical place to have that coordination function is in the hands of the person doing comprehensive care and again is stronger more powerful in a relationship of trust. I want my wife, my mother, my employees to have the kind of relationship so when it comes to difficult conversation (death panel conversation) they have someone they know trust and who has comprehensive information and understand of my family member employee.
Going forward in time because we now have the tools the power to do real care coordination and increasing we will have real data, real clinical decision support we will reach a place in the not to distant future when it will be consider unethical immoral against any and every oath we take to do harm – to deliver uncoordinated care to deliver episode based car not comprehensive care to deliver disintegrated care vs integrated care.
In order to be meaningful this relationship has to support the longitudinal and comprehensive care of patients. Technology can support that relationship by improving communication. It can allow expanded communication with a patient; it can empower the doctor not to forget to ask an important question be it about the patient’s personal life or a key factor in the healing process. Smarter healthcare can send reminders of care compassion, reminders that express a doctor’s investment in a person who yearns for a personal relationship with their healer. A smarter healthcare system can help ensure that critical information and updates, that might otherwise be missed in a busy doctors office and presented in dashboards – front and center, or are sent via email or text messages to Care Coordinators. Smarter healthcare makes sure the right drug is used on the right patient at the right time, taking into account the person’s genetic makeup and other medications they are using. It ensures the authenticity of pharmaceuticals and the security of patient information. It changes everything from how healthcare organizations do business to how they enable their employees to collaborate and innovate.
But in all of this there needs to be accountability and it need to be done down at the coal face of the doctor patient relationship in the face of a caring relationship.
Look the VA gets it they are migrating 100% to PCMH, Kaiser gets it Geisinger gets it these are all “ACO” that are now going back to a base of PCMH why would we want to do that mistake all over again.
Bottom line PCMH/ACO same thing one view from the top down one from the bottom up if we try and make them two different items we fail.
NCQA needs to have PCMH/ACO, ACO/PCMH one can not qualify for and ACO unless you have a foundation of PCMH period. Going forward in the future no ethical doc should be part of any care deliver that does not have PCMH the principles that all of primary care agrees on as it foundation.
First and foremost -- Patient Centered Medical Home is an effort to address the high cost/low value situation we find ourselves in as large employer buyers of care. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford.
But we the buyers have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,
When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care (PCMH) and 2) the way primary care is financed (ACO). Our premise is that someone agreeing to be a comprehensivist like a primary care doc or an infectious disease doc caring comprehensively for their patient is the only natural locus of control of health care quality and costs. Point two this need to be funded and financed in an accountable way and ACO it the way to do that. PLEASE PLEASE do not try to separate how the money flows (ACO) from the principles all primary care has agreed on (PCMH) if you do we are in real trouble and the readers should all know that.
Primary Care/comprehensive care as defined by the principles of the PCMH It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.
As large employers our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care as a work around of the core problem and not face the real issue head on. If stand alone disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective/comprehensivist, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, with the right tools is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Stand alone disease management programs which are not delivered at the point of care present a Band-Aid approach to problem solving. These kinds of work a rounds instead of addressing those problems directly have in fact created additional, expensive, fragmented responses to the primary problem.
For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to "pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.
Although we tend to focus on the problems we face, there are reasons for a great deal of optimism-optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum. We the large employers for the first time are at the table with the national health benefit companies and primary care professional societies. Let’s seize this opportunity and make the fundamental changes we have been asking for as large employers.
While I would not argue that primary care/ comprehensive care should be all things to all people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.
For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.
So how do we as large employers join the ranks of other systems like the VA and Denmark that have driven as much as 60% of the inefficiencies out of the system.
In step lock with our partners, the primary care providers, we are making it clear to the healthcare benefit companies that we deal with that as an employer buyer it is no longer business as usual. Let also be counted on as employers to send the same message to the other large healthcare buyers Health and Human Services, CMS, Medicaid, Federal Employees, DOD TRICARE, the White House, Congress, State and local government and others.
We demand as the buyer we demand of ourselves and our Healthcare benefit companies:

Comprehensive, continuous, patient centered personal and holistic primary care which is based on strong relationships between patients and their physician -- this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.

You try to stand up a separate ACO without PCMH we will reject it totally and completely Honest – it will not happen!!


To reiterate, no matter how well-intended, if other entities (hospital systems, payer networks, etc.) are put in control, the ACO projects will simply fail. I encourage physicians to get involved and only support initiatives that best serve their patients.
Perhaps there might soon be opportunities to chose to play a role other than the victim?