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The rise and fall of the patient-centered medical home


Why a PCMH pioneer may abandon the model in his practice

There is an old adage in medicine, that you want neither to be the first nor the last physician to prescribe a new therapy for your patients.

In a similar vein, physician implementation of the practice transformation rave known as the PCMH encompasses a large bell-shaped distribution curve, from early adopters who pursued the model over a decade ago, to those clinging to a more 1970s-vintage practice style.

I was on the earlier side, being one of the first 10 practices in my state to gain National Committee for Quality Assurance (NCQA) Level III PCMH recognition (the highest available) under the original 2008 standard. I even worked as a senior physician reviewer for the NCQA, reviewing physician practice applications for recognition. The payments that came with being a PCMH were only OK, ranging from $3 to $7 per member per month, and the attribution always seemed to be less than half of the actual patients I was seeing with other payers.

Related:PCMH accreditation: Is it worth it?

This year I am considering not maintaining PCMH recognition. It is basically a marketplace decision. The payments from insurers to maintain my care coordinators on payroll, to continue externally reporting from my large data registry, and all the other trappings of robust PCMH just are not sufficient.

I am in an accountable care organization, and so I may need to “keep it up,” I suppose, for the Medicare shared savings I hope to see in third quarter 2016. But the PCMH payment model has never caught on with the top five (soon to be three) national commercial payers at a level that is truly sustainable for the vast majority of family physicians, internists, and pediatricians.

Meanwhile, the next big thing in primary care payment reform is here: direct primary care (DPC). DPC has almost a cult following. Its numbers are growing rapidly, and to economists this means that it has the potential to become the dominant form of primary care reimbursement. PCMH and advanced primary care payment models have plateaued, suggesting a matured business model phase. The overhead costs of PCMH have to be paid one way or another, and payers have not been willing to make those payments in the amounts or attribution levels physicians hoped for.

As more and more physicians adopt the DPC payment model, the lower costs of the model becomes a disruptive innovation, bringing lower healthcare costs. Whether DPC will create a reduced standard in the delivery of healthcare quality remains to be seen, and the concern for quality is perhaps the largest hurdle DPC must overcome. Having said that, the PCMH movement has not always resulted in better quality per se, and there is no evidence yet that DPC erodes quality.

But if you are considering DPC for your practice, remember: You neither want to be the first nor the last to try a new payment model.

John L. Bender, MD, MBA, FAAFP, is senior partner and chief executive officer of Miramont Family Medicine in Colorado, and a member of the Medical Economics editorial advisory board. Send your comments to

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