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Monday Feb 18, 2013

Residencies Face Barriers to Teaching PCMH

I believe that the patient-centered medical home (PCMH) is the future of primary care. The model has been proven to provide cost effective and high quality health care, and some payers are beginning to recognize its value.

At the University of Nevada School of Medicine, where I am chair of the department of family medicine, we have developed curriculum for students that includes required reading, faculty lectures and shadowing faculty. It's working out well for student education.

But in Nevada, and elsewhere, teaching the PCMH model to residents remains an issue that needs a solution. It's a looming problem for residencies because, starting in 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require residencies to teach population management. Although population management sounds big and broad, the reality is that PCMH is the most likely model to fill that accreditation requirement.

According to an estimate by the Association of Departments of Family Medicine (ADFM), one-third of residencies already are teaching PCMH, one-third are working to implement it into their training programs and one-third have made no progress in implementing it.

That leaves many programs with a lot of work to do in the next two years. Unfortunately, adding curriculum with no new resources amounts to an unfunded mandate. How will these programs adjust?

The good news is that help may be on the way. For years, the AAFP, and a coalition of other primary care groups, has been urging the Health Resources and Services Administration (HRSA) to study the development of PCMH curriculum in primary care residencies. A pilot project, funded by HRSA, is expected to start this spring at four universities (encompassing a total of 12 pediatric, family medicine and internal medicine residencies).

The goal will be to develop a unified curriculum that could be deployed in any of our nation's roughly 1,000 primary care residency programs.

Of course, the lack of standardized curriculum is just one barrier to making a residency program a PCMH. Population management is impossible without a robust electronic health record (EHR) system, and some programs just aren't there yet.

It's estimated that implementing an EHR in private practice costs roughly $80,000 per full-time equivalent physician. Here in Nevada, we have six departments in Las Vegas and four in Reno. The cost to implement our new EHR is estimated at $6 million. For some training programs, the cost will be even higher.

Grant money has helped some residency programs move forward with EHR implementation, but others lack the resources to take that step, which is a shame because the PCMH is good for patients. It stresses preventive care, engages the patient and encourages a healthy lifestyle. It also benefits payers by lowering costs, improving care and leading to better outcomes(www.pcpcc.net).

We can talk to our residents about PCMH, and we can teach them about things such as team-based care. But without an established curriculum and robust EHRs, residents are only getting a taste of what the PCMH is all about.

And those who don't learn the PCMH in residency will be forced to learn it as new physicians. Surely, there is a better way. We need a consistent method of teaching PCMH at all levels of education.

Payers stand to reap the benefits of physicians who practice in the PCMH model. So payers should recognize that teaching students and residents in this model is costly and do what they can to help facilitate that training.

Daniel Spogen, M.D., is a member of the AAFP Board of Directors.

Posted at 04:22PM Feb 18, 2013 by Daniel Spogen, M.D.

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