Physician Practice Too Small for a PCMH? Think Again

Making your physician practice into a patient-centered medical home can seem like a daunting proposition. There's investment involved, sure, in technology and in staffing. Depending on a lot of factors, it could be a big investment for a business that likely doesn't generate a whole lot of margin. And I'll concede that the return on that possible investment is murky at best. But if you're not trying to develop a medical home out of your primary care practice, don't let being "too small" be your excuse.

Why? Practices don't get much smaller than that of Joseph Mambu, MD. And he's doing it.

Mambu is one of only two full-time physicians at Family Medicine, Geriatrics and Wellness in Lower Gwynedd, PA, although he also employs another part time. He also has three part-time nurse practitioners. He's an early adopter of the medical home concept, however, and he is certain there will still be a place for the small physician office under healthcare reform, provided they make some very big changes, as he has, over the past five years.

The medical home, also known as the patient-centered medical home, briefly, is a largely theoretical concept that envisions a location where patients can obtain their primary, preventive, and acute medical services at the same location and through the same physician. When they need inpatient or specialty care, the primary care physician's care team coordinates it and works to stamp out unnecessary duplication of tests and services.

In its most evolved state, the medical home physician uses decision-support tools created through evidence-based medicine protocols, quantitative indicators of quality, health information technology, and feedback on physician performance. The problem: reimbursement doesn't necessarily encourage their growth—at least not yet.

Mambu was lucky in some respects. Having spent 22 years in a group practice environment, he despaired of ever being able to care for his patients with chronic conditions properly.

"My interest in chronic care began back in medical school," he says. "It's a very tough part of medicine and I never thought we did a great job with chronic care, even though it's been my career-long ambition."

But it was an ambition that lay dormant for years, as technology and payment incentives never encouraged the creation of a true patient-centered medical home. Even in a large health system, which bought the practice where Mambu spent 22 years. 

"I thought being part of a large health system would be a model to help patients get this type of coordinated care," he says, explaining the sale.

He complains that the health system wasn't interested in the medical home, only the profitability of the practice.

10 years ago, at the age of 52, he thought, "if I don't do it now, it'll never happen."

"It," was starting his own practice by hanging a shingle, putting an ad in the paper, hiring a scheduler and a nurse practitioner, and doing house calls. That happened in 2005.

He got involved with the American Academy of Family Physicians, which was planning a demonstration project on how to revamp primary care as a way to show the viability and value of the primary care physician in an era in which most young doctors were eschewing that career track in favor of specialization.

His was the only practice in the state to be selected. It's how he got his practice's electronic medical record, and it's where he developed a holistic method for treating chronic conditions among his patient population. After that demonstration ended in 2008, he got into a state-level medical home and chronic care initiative. The chronic care model backs into the patient centered medical home construct, he says.

"Patient centeredness doesn't mean doing what the patient wants. It's about having the time to reestablish a relationship and understand what's going on through the patient's eyes, and seeing the patient in the context of community and support systems," he says. "It means having the time to get to know the patient the way we used to do it before it became a volume business where it was necessary to see 40-50 patients a day."

He's hired two RNs who are "case managers slash health coaches slash office-based experts," he says. In addition, there is now a practice administrator and medical assistants.

In hindsight, he's glad the experiment with the hospital-owned practice didn't work out.

"Had they not mistreated me, I wouldn't have had the gumption to start my own practice and would have never gotten involved with this movement," he says. "It was expensive to do what we did, and there's no real reimbursement. Salaries haven't gone up, but we're not in it for making lots of money. I've always wanted to do this--it just took me 25 years."