FROM JAMA INTERNAL MEDICINE
The way Edward J. Bujold, MD, sees it, the patient-centered medical home (PCMH) as a model of care has become unsustainable in the current health care landscape.
In an opinion piece published online in JAMA Internal Medicine, Dr. Bujold describes how he reinvested Medicare incentive payments to build a solo family medicine practice into a patient-centered medical home with a staff of 14 full-time and part-time employees, including an embedded psychologist, pharmacist, physical therapist, and dietitian.
“Although only about one-quarter of the patients cared for at our practice are Medicare beneficiaries, other insurers and those they insure have benefited immensely,” wrote Dr. Bujold , owner of Granite Falls (N.C.) Family Medical Care Center (JAMA Internal Med. 2017 Sept 25. doi: 10.1001/jamainternmed.2017.4651 ).
The bonuses from the Center for Medicare & Medicaid Services’ Meaningful Use and Physician Quality Reporting System “enabled us to develop and support the financial structure required to create the PCMH,” he noted. “For the most part, this financial support ended in December 2015. Our financial losses in 2016 are enough to jeopardize the foundation of our PCMH.”
When Congress voted to end the Medicare Sustainable Growth Rate formula, the Primary Care Incentive Payment Program authorized under the Affordable Care Act also ended.
“During 2017, a value-based payment system to replace and hopefully increase our reimbursement is to be phased in,” Dr. Bujold wrote. “The problem for practices like ours is the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015/Merit-Based Incentive Payment System (MACRA/MIPS) does not take effect until 2019, and there is no guarantee we will receive any more money than we receive now. We may receive less.”
Citing studies from Oregon and from the Patient-Centered Primary Care Collaborative , Dr. Bujold said that for every dollar invested in primary care, the overarching health system saves about $13.
“The 80% reduction in hospital admissions for our practice is a testimony to these savings,” he stated. “The irony for me is that, 5 years ago, I generated a substantial amount of my income from the hospital portion of my practice, because I was seeing an average of five patients per day in the hospital.”
As a result of transitioning his practice to a PCMH, however, he now sees “one or two and sometimes no hospital patients per day.” At the same time, his office’s overhead cost is 65% and increasing – up from 50% when he opened his practice 31 years ago.
Dr. Bujold noted that about 60% of primary care physicians are employed by hospital organizations, which are able to charge a facility fee “above and beyond what the independent primary care physician charges in his or her office. This increases the cost of care in general by 20%-30% and the patient out-of-pocket costs by a factor of 2 or 3.”
In his view, “we have large hospital systems, the pharmaceutical industry, large insurance companies, and other moneyed players and their lobbyists with vested financial interests. The view from my practice is that these industries seem to hold all of the cards, and it is very difficult to move forward. I am more pessimistic than I was 5 years ago.”
Despite his current misgivings, Dr. Bujold ended his opinion piece by stating that the best way to “heal the health care system in the United States” is one directed by primary care and rooted in high-functioning PCMHs.
“The trajectory must be changed,” Dr. Bujold wrote. “In many areas, payers are not supporting PCMH transformation, and states are not engaging practices or working with Medicare to support transformation. Investing in high-functioning PCMH practices is the right thing to do.”
Dr. Bujold disclosed that he is employed by KPN Health as chief physician strategist and is an advisory board member of the Patient-Centered Primary Care Collaborative.
