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The American College of Emergency Physicians (ACEP) Rains on the Patient Centered Medical Home's (PCMH) Parade

Posted Dec 02 2008 3:08am
In case you missed it, the killjoys over at the American College of Emergency Physicians (ACEP) released a tetchy statement on the unintended financial consequences of widespread implementation of the Patient Centered Medical Home (PCMH). They point out that emergency rooms are an important part of the safety net regardless of insurance status. Therefore, if the PCMH has any potential to change the role of that safety net, the ACEP wants to know about it ahead of time. Ulitmately they say more research is needed.

If you read the statement, they make some good points. Compensation for primary care physicians should be increased (check). It’s possible the PCMH won’t solve the overall primary care shortage (check, they must’ve been reading the Disease Management Care Blog). Small primary care physician practices will struggle to fulfill the criteria necessary to meet the definition of a PCMH (check, good point). If, as a result, patients shift to PCMH style large practices, they may still end up seeing a ‘host’ of different health care providers with little continuity of care (good point not considered by the DMCB: outside of the pediatrics literature, do large practice PCMHs perform well in assuring is access to a personal physician?).

On the other hand, some other points in the statement seem rather self-serving. Since the overall financing of health care is a zero-sum game, they fear a shift of money to the PCMH may mean less money for their admittedly overstretched emergency rooms (but, won’t the PCMH reduce unnecessary, wasteful and probably low margin – at least compared to all those juicy trauma cases - ER utilization?). While PCMH advocates deny it will restrict access to specialists, the ACEP fears that could be an outcome anyway (not so, says the classic PCMH literature: optimally coached patients will know when they do and don’t need an ER. Gatekeeping is unnecessary). According to the ACEP, primary care sites should promise to continue to offer medical home services even if a patient loses their insurance (which would help keep the uninsured away from emergency rooms by making the primary care physicians provide a service for free?). Last but not least, for the PCMH to work, they state universal coverage is needed (hasn’t it been the commercial insurers leading the way on the PCMH with their pilots?).

The DMCB recalls that our Surgical colleagues are also being sour pusses. And the AHIP isn’t exactly being all that gung ho either. So the DMCB has a suggestion for the PCMH enthusiasts: get yourselves a theme song. Here’s a suggestion.
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