Some physicians noted challenges related to maintaining PCMH status including additional responsibilities for both physician and non-physician staff, making it difficult to complete daily duties. As one physician described, "The list of what I'm supposed to be doing in a medical home keeps growing and we have to be creative about how to provide that because there isn't enough time." Another challenge was documentation to maintain PCMH-recognition, which some physicians considered time-intensive and labor-intensive: "You don't realize how much work it is to maintain certification."
|TABLE 4. Pediatricians' and Family Physicians' Perceptions of the Impact of PCMH Processes on Patients and PCMH-Recognition on Practices|
|Most physicians had not seen data to track impacts on patients but could discuss anecdotes or hypotheses about the perceived impact of care in a PCMH.|
|"I don't know that we have good outcomes data yet. We run tons of reports and we follow up, but I don't know if it's been long enough to tell if we have outcome improvements" (pediatrician in an FQHC).
"It's not like asthma [special health needs]. There are so many different disease states, that we don't have data that can show 'the more you do of this, the fewer admissions you'll have'" (pediatrician in a large, integrated system).
"When special needs kids go the ER, they are hospitalized at a much lower threshold than other kids because ER doctors are intimidated by their conditions and err on the side of caution. When kids come to our clinic for acute care, it's different because we know what their baseline is and are more likely to decide we can manage something outpatient. Also, we help them coordinate with good home care that helps keep kids healthy day in and day out" (pediatrician in an independent, multisite practice).
"One thing that applies to kids with special needs is monitoring whether they're getting the care they need . You need to get the ones who are coming in and the ones who aren't coming in it's more proactive [care in a PCMH]. ER visits are lower with asthmatics. You'll be less likely to go to the ER if you are on your controller in the fall. If no one calls you and reminds you [like we do] and if you had a good summer, you'll forget and then you'll be in the ER in the fall" (pediatrician in a large, integrated system).
"The chronic care coordinators, qualitatively, are a tremendous asset to families. It's hard to measure quantitatively. They help families with understanding their Medicaid benefits, working with an autism diagnosis, whatever. They can provide a lot of services and education to families" (pediatrician in a large, integrated system).
|Many physicians perceived PCMH-recognition as beneficial to practices' finances and reputation as well as a stepping-stone toward participation in other system transformation initiatives.|
|"Some of the insurance companies have started to create plans focused around this [PCMH-recognition]
. [The insurance company] definitely saw some value in [NCQA-recognition] and is throwing some money at it. So we're part of that and we're going to get some per-member-per-month stipend
" (family physician in an independent, single-site practice).
"We were also involved in a pilot for an ACO. We hope, in the future, that there will be payment based on performance for that" (family physician in an independent, single-site practice).
"It's helpful for fundraising. It must look great. Very few in our area have this designation. We get money from the City Council and other places too" (pediatrician in an FQHC).
When asked about potential downsides of operating as a recognized PCMH, some physicians replied that the process required a large financial investment from the practice. One physician described the costs involved in implementing an EHR and another commented that getting recognized meant "a lot of upfront money and staff costs, without a lot of reimbursement." Two physicians reported staff turnover related to adopting new PCMH features at their practices, including one employee leaving due to discomfort with the transition to an EHR and another because of the shift in practice culture from a "doctor-says approach to a team approach."
Challenges and Opportunities to Improve Care for CSHCN in a PCMH
All physicians tailored some care processes for CSHCN. Nonetheless, they described several factors affecting their ability to improve primary care for CSHCN in their PCMH practices. Many physicians described how an established system for sharing information with specialists and children's hospitals, often through EHRs, was critical to their ability to coordinate and manage care for CSHCN. An equal number of physicians provided examples of how inadequate communication and information sharing with these providers undermined their ability to provide timely and coordinated care. Physicians cited both a lack of effort from specialists and hospitals and a lack of interoperable HIT as contributing factors.
Consistent with other PCMH studies, sustainable financing was a concern for some physicians, particularly for care coordination activities. Physicians also cited other family and system factors that they perceived impeded their ability to improve care for CSHCN, including limited family follow through on treatment plans due to lack of engagement or financial constraints, unstable insurance coverage for families, and bureaucratic requirements from payers.
A few physicians also emphasized that CSHCN are a heterogeneous group that includes a wide range of chronic conditions, making it more difficult to identify and care for patients with less common conditions than for those with conditions that present more uniformly and have clear care guidelines, such as asthma or type II diabetes in adults. These physicians said that the heterogeneity of the overall CSHCN group made it challenging for practices to build registries and develop proactive tracking systems. This heterogeneity also results in a lack of pay-for-performance targets, and other than altruism, there is less incentive for providers, especially family physicians, to invest in systems of care for complex CSHCN. One physician said, "With diabetes, it's pretty cookbook. You know, is their A1c below seven? But with the [CSHCN], each one of them has their own varying needs and it's much more complicated." She continued, "It has to start with identifying them and deciding what you want to do with them. Do you put them on a special list where we call them on a regular basis, or do we just check their chart more often? This is a higher level of being a medical home -- the next step. That's where practices struggle because it's not a homogeneous group."
Expanding the Transformative Power of PCMH-Recognition
When asked what features they thought were missing from the NCQA-recognition process, some physicians expressed that recognition was too heavily metric driven and may underemphasize features of care that are more difficult to measure, namely patient experience. Physicians described how NCQA's recognition emphasized measurable infrastructure and system characteristics such as a practice's telephone system or accessible hours and its implementation of evidence-based standards of care, but that it failed to address "softer" characteristics. As one physician explained, speaking about the effort her practice spends ensuring high-quality communication with patients and specialists, "you can get certified [as a PCMH] and choose not to do those things [focus on high-quality communication]. Those are the softer things that the certification process alludes to, but are hard to measure." Another physician said, "There's less emphasis in [NCQA-recognition] on things that patients would actually see and experience. It takes a whole lot more to make [patients'] experience positive."