RE: a few quick questions about your plans for pcmh

March 6, 2009

D. Egly, M.D.

Doctors Egly & Associates P.C.

11 E pleasant Ave

Sandwich, Il 60543

kevin_egly@...

We are not going to do ePrescribing.

We will not do NCQA.

We are high tech/high touch ideal medical practice.

We have documented quality measures 15-25 % above national norms with the ACP:Center For Practice Improvement Project with Dr. Barr.

We have been audited for being a medical home by consultants from ACP, but found we did not have eprescribing and a few other technical shortfalls on the medical home.

They did find great quality and cost effectiveness. They did think this is what was needed in the solo-practitioners office across America, but they could not quantify it by NCQA standards.

I could. The cost of PQRI reporting was higher than the reimbursement. The quality was already there. We only have one patient with A1C above 9. Why report on all those that are controlled? We worked for over one year with Illinois State Quality Alliance and were one of two paperless offices that submitted data to PQRI, but they and our EMR vendor could not get the data out of our EMR. Hours and hours of wasted time.

Eprescribing has been evaluated and the added time to document prescriptions and the cost of eprescribing itself does not pay or improve the safety of a printed prescrition handed to my patient or faxed to the pharmacy. Again the quality is already there and has been for the last 5 years of our practice. We run at extremely low overhead of $2/min. So any increase in time for reporting costs us and the patient money.

We did PQRI on 20 diabetics in 2008 took an extra day of appointments probably worth it.

But reporting on every parameter at every diabetic visit is not practical or prudent or financially responsible.

Lastly, for NCQA certification there has to be a benefit to my practice in efficiency, my patients in quality, and myself financially. Otherwise I am already providing great patient care and I need to be compensated appropriately.

Finally, I know what it costs to provide great quality care in a primary care setting it averages out to be about $1/day per patient across all insurance. So for $365/year or $30/month I could greatly improve services to my patients. Right now I believe medicare pays only $120/year while the patient pays $130/year on average for my services to medicare patients. That is only 66 cents per day.

America can do better.

Sincerely,

D. Egly, M.D.

Subject: a few quick questions about your plans for pcmhTo: "practiceimprovement1" < >Date: Friday, March 6, 2009, 11:13 AM

I have a state afp board meeting coming up, and i always feel very much the minority when i question the validity or feasiblity of the MedicalHome, so to arm myself (since I am often told I am alone in my feelings, and that there is no other way), if you have a few seconds to provide me with the following data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me so that, if nothing else, i don't feel like a complete lunatic when i am surrounded by the rest of the board. I would like to change the name of the group to NJAPSPCMH (new jersey academy of practitioners supporting a patient centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

March 6, 2009

,

I know how you feel. This is how I feel with every e-mail

communication with the GA committee though in person, I found our opinions were

not so diverse.

And I announced at our Family Practice Department meeting last

night (5 of us attending) about the Horizon project and no one but Marty

Swinehart had heard of it.

PS: Will you be going to that meet and greet with the

political bigwig? I am going to go.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of

Crowley

Sent: Friday, March 06, 2009 12:13 PM

To: practiceimprovement1

Subject: a few quick questions about your plans

for pcmh

I have a state afp board meeting coming up, and i always

feel very much the minority when i question the validity or feasiblity of the

MedicalHome, so to arm myself (since I am often told I am alone in my feelings,

and that there is no other way), if you have a few seconds to provide me with

the following data:

what is your specialty? Family Medicine

what state do you practice in? (in what state do you

practice?) NJ

do you plan to attempt ncqa certification for a patient

centered medical home? No, but I do plan to be secretly prepared.

and, if you feel like answering, why or why not? Too time consuming

and expensive. Little time I have can be spent more constructively on

things that will directly improve patient care.

i hope this is not a violation of list protocol, it is

helpful for me so that, if nothing else, i don't feel like a complete lunatic

when i am surrounded by the rest of the board. I would like to change the

name of the group to NJAPSPCMH (new jersey academy of practitioners

supporting a patient centered medical home), but i guess that wouldn't fit on

the shirt logos...

thanks, and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 6, 2009

PCMH (as far as I know) is not yet an

option for us in CA, so we haven’t given it consideration yet. In

response to your questions:

Internal

Medicine

California

Maybe

Will

depend on whether or not the benefits of doing so outweigh the costs (not

necessarily financial) – same reasoning as all of our other

decisions

Pratt

Office Manager

Oak Tree Internal Medicine P.C

Roy Medical Associates, Inc.

From: [mailto: ] On Behalf Of Crowley

Sent: Friday, March 06, 2009 9:13

AM

To: practiceimprovement1

Subject: a

few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much

the minority when i question the validity or feasiblity of the MedicalHome, so

to arm myself (since I am often told I am alone in my feelings, and that there

is no other way), if you have a few seconds to provide me with the following

data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered

medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me

so that, if nothing else, i don't feel like a complete lunatic when i am

surrounded by the rest of the board. I would like to change the name of

the group to NJAPSPCMH (new

jersey academy of practitioners supporting a patient

centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 6, 2009

I have a state afp board meeting coming up, and i always feel very

much the minority when i question the validity or feasiblity of the

MedicalHome, so to arm myself (since I am often told I am alone in my

feelings, and that there is no other way), if you have a few seconds to

provide me with the following data:. For quite a while now when I speak up I introduce myslef as an alien. I just sorta warn them mildy -humorously but I rehearse as much as I can having been nailed a few times ,and I speak very pointedly in defense of primary care and what a mess it isin this country .I tell them, who ever the audience is, and the worst audience I encoutner being my medical staff locally, I tell them " I am in primary care and I work alone. I am not subsidezed. I see things differntly. I changed the way I work a few years ago. I work differntly I see thigns differntly. I put my money where rmy mouth is . I s ee everyone the day they call and I measure what I do. (I say some part of that stuff depending on the situation In case this is helpful to you TAc) IN deed I ge t push back and stared at and stuff but waddya gonna do NOT SPEAK?? ONce or twice I have gone home feelinglike slime with serious anti perspirant failure but I mean waddya gonna do?Sometimes people tell me later that they were glad I spoke up or agree or a long time later they begin to come around Hence do start speaking now!

what is your specialty? fp

what state do you practice in? (in what state do you practice?) MAine the way life should be is what it says on I-95 as you come into MAine

do you plan to attempt ncqa certification for a patient centered medical home? Are you crazy?? This means no I did look at the certification and go through it and I can see that as KAren says I am secretly preprared but I have no intention of -ante-ing up money and the time to get it officially done I am allso not going ot do epresribing right now becasue if I did some software that was free it costs me double entry - not free and mucho errors! And if I use my emr's new e prescribing module it costs 1200 a year about twice the best ithinkI could get from emdicare . IF they get to the penalize me or do it part- i got two years thern--I may think about it

and, if you feel like answering, why or why not? Becasue I cannot afford it, IT would cost a day's wages plus god knows how many hours. I am not in possession of any information that saya it will benefit me in concrete way X and concrete way Y, nor has it been said to me that it will penalize me so far to not do it in ways X or Y In other words why would I do it?

i hope this is not a violation of list protocol, it is helpful for

me so that, if nothing else, i don't feel like a complete lunatic when

i am surrounded by the rest of the board. I would like to change the

name of the group to NJAPSPCMH (new jersey academy of practitioners

supporting a patient centered medical home), but i guess that wouldn't

fit on the shirt logos... Yeah you wanna work on the acronym maybe you can do something with MH which can be for either medical home or mental health...

thanks, and happy friday.

tac

March 7, 2009

Hi ,

I am practicing Family Medicine in Drain, Oregon. And, like I said, when I read the requirements for the Medical Home, I just laugh. Let me see: I should get the HbA1C for the little lady who lives in a tent in front of the cave on the 30 acres she calls home just behind the North Branch of the Umpqua... (and see if she will pay the co-pay? or the lab copay? or stop using the herbal hibiscus infusion she treats her hypertension with in favor of something that big Pharma sells?) And then I get to have someone in the pay of Big Pharma check out my clinic and dictate my EMR system, and by-the-by buy their e-prescription system that does not pay for itself, using the "profit" I get from the little lady in the cave?

These people just crack me up.

Joanne Holland DVM/MD Drain, Oregon

Subject: a few quick questions about your plans for pcmhTo: "practiceimprovement1" < >Date: Friday, March 6, 2009, 9:13 AM

I have a state afp board meeting coming up, and i always feel very much the minority when i question the validity or feasiblity of the MedicalHome, so to arm myself (since I am often told I am alone in my feelings, and that there is no other way), if you have a few seconds to provide me with the following data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me so that, if nothing else, i don't feel like a complete lunatic when i am surrounded by the rest of the board. I would like to change the name of the group to NJAPSPCMH (new jersey academy of practitioners supporting a patient centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

March 7, 2009

what is your specialty?

Family

Medicine

what state do you practice in? (in what state do you

practice?)

Virginia

do

you plan to attempt ncqa certification for a patient centered medical home?

Working

on it—very slowly

and,

if you feel like answering, why or why not?

I fear that by just saying “bah

humbug” immediately gets me dismissed as someone not interested in moving

family medicine forward, but if I were able to qualify as a Level 3 PCMH (and I

think I can), then hopefully I can work from within the system to tell people the

certification is ridiculous and will not result in a better or more efficient

system. Why?:

1) A huge

portion of the PCMH is database stuff—Do you

have the EMR necessary to collect the data? Do you have protocols for how to

handle the collected data? Do you have authorized personnel who can then

translate the data to the patient and to the government?

My simple

question is “how many docs enjoy doing billing?” The answer is, of

course, none. Why? It is a mind numbing, frustrating, infuriating process of data

processing. So, how many docs will do there own data collecting? Well, none. So

are we just creating an entirely new field of “chronic disease analyst”

so we can then pay someone else the extra income we are making (if we make any)

so the appropriate boxes will be checked? Well, yes. So how does having more

people between the doctor and the patient strengthen the doctor-patient

relationship and how does that impact a med student’s decision to choose

family medicine as a career?

2) The PCMH

criteria are skewed toward large practices—I have to write up protocols

stating that I have written guidelines on how to treat diseases so all the

providers (which would be me) follow the same guidelines. Umm, I hope that I am

relatively consistent with how I treat my diabetics, but the protocols must be

written.

3) There is

little evidence which shows incentive payments for data analysis actually

improves outcomes. This is a little scary to talk about, but there was a study (

et al., “The Impact of Pay for Performance on Diabetes Care in a Large

Network of Community Health Centers”) which showed that P4P initiatives

lead to increased testing, but that there was little impact on the results. In

fact, overall HgbA1C went up showing that getting the data does not necessarily

mean that data will impact the patient’s life resulting in better

outcomes. Think about this for a moment. The entire argument for the patient

centered medical home is that it will save money through providing superior

care, but there is paltry evidence (that I have seen) which shows giving docs

incentives to meet a laundry list of guidelines works. This is no surprise

because data collection is not as important as a relationship in instigating

change.

4) Does going through the process

actually make a practice better? Not likely. Practices which are doing a good

job will likely get certified but the process will not make them better (as

alluded to). Poor practices cannot get certified so they won’t try.

Others will do what they need to do to get certified but will not change the

way they practice. This is because changing behavior, even dysfunctional ones,

is very difficult.

I always go back to the basics in such

passionate discussions. Does what I am doing improve my relationship with my

patient? Having looked through the certification process a fair amount, I do

not believe getting certified does. And, if it does not improve that

relationship, then it will not succeed in improving quality or stopping the failure

of primary care to recruit new docs into the ranks? No. So, is it a potentially

dangerous distraction? Yes. That is my great fear.

,_._,___

March 7, 2009

This is a very important issue.

We have to step back and ask the question:

What are we trying to accomplish?

What I hope is that the NJAFP is trying to

help its membership practitioners remain vital contributors to their

communities by providing excellent health care for reasonable compensation.

The question “will PCMH get us

there?” is the next most important question.

Brady, Egly, & Antonucci respond very

well to this.

When we step back and look at the goal of

improved population health, improved experience of care, reduced per-capita

cost of health care, we will likely agree that a system achieving these

meaningful goals is doing a good job – it is in the words of the

Commonwealth Fund a “high performing health system.”

Such systems are founded on comprehensive

primary care.

Comprehensive primary care has certain

cardinal features:

First point of contact = “I have no

problem getting care when I need it”

Relationship over time = “My primary

care practitioner knows me as a person”

Broad array of services = “My PCP

takes care of the bulk of my health care needs”

Coordination of care = “My PCP

coordinate any care I need from the health system”

Bob Berenson (who has authored and

co-authored some very important articles on health policy lately and headed up

the PCMH review work for ACP) tells an interesting story when he describes what

it was like going around the country assessing practices as “medical

homes.”

He visited several that met all the NCQA

criteria and had all the electronic bells & whistles. Then he visited

one that didn’t have the bells & whistles but was a very small practice

with superb access, superb continuity, and exemplified the core values of

comprehensive primary care. Bob said that the latter practice didn’t

cut it as an NCQA “medical home” but would be where he would

send his parents.

Folks, the NCQA model not only doesn’t

effectively get at the core of what defines high performing health systems, it

also diverts our time, energy and money into things that have very little to do

with quality, care, and the compassion that is the essence of what we do for

our patients. As far as I can tell, achieving “Level 3 recognition”

is an expensive diversion down the wrong road and will lead to self congratulatory

delusion that somehow we’ve created a better health care delivery system.

Gordon

From: [mailto: ] On Behalf Of Crowley

Sent: Friday, March 06, 2009 9:13

AM

To: practiceimprovement1

Subject: a

few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much

the minority when i question the validity or feasiblity of the MedicalHome, so

to arm myself (since I am often told I am alone in my feelings, and that there

is no other way), if you have a few seconds to provide me with the following

data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered

medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me

so that, if nothing else, i don't feel like a complete lunatic when i am

surrounded by the rest of the board. I would like to change the name of

the group to NJAPSPCMH (new

jersey academy of practitioners supporting a patient

centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 7, 2009

Folks, the

NCQA model not only doesn’t effectively get at the core of what defines

high performing health systems, it also diverts our time, energy and money into

things that have very little to do with quality, care, and the compassion that

is the essence of what we do for our patients. As far as I can tell,

achieving “Level 3 recognition” is an expensive diversion down the

wrong road and will lead to self congratulatory delusion that somehow

we’ve created a better health care delivery system.

Gordon

This is

exactly the case. I have had all the parts that the NCQA requires for a

Level 3 medical home in place for well over a year now, but every time I

put time and energy in to creating the documentation required and writing the

nonsense policies required by NCQA, it puts me behind in patient care and takes

me away from activities that would actually improve the health of my

patients.

Like

Brady, I still intend to get the Level 3 recognition simply so I will have some

standing to suggest changes, but it will be very slow, so as to minimize the

harm to my patients from the process.

It is

really a shame that, at this time when we need to create a high-performing

health system in this country, our attention is diverted to administrivia such

as the NCQA recognition process.

dts

From:

[mailto: ] On Behalf Of L. Gordon

Sent: Saturday, March 07, 2009 10:28 AM

To:

Subject: RE: a few quick questions about your

plans for pcmh

This is a

very important issue.

We have to

step back and ask the question: What are we trying to accomplish?

What I

hope is that the NJAFP is trying to help its membership practitioners remain

vital contributors to their communities by providing excellent health care for

reasonable compensation.

The

question “will PCMH get us there?” is the next most important

question.

Brady,

Egly, & Antonucci respond very well to this.

When we

step back and look at the goal of improved population health, improved

experience of care, reduced per-capita cost of health care, we will likely

agree that a system achieving these meaningful goals is doing a good job

– it is in the words of the Commonwealth Fund a “high performing health

system.”

Such

systems are founded on comprehensive primary care.

Comprehensive

primary care has certain cardinal features:

First

point of contact = “I have no problem getting care when I need it”

Relationship

over time = “My primary care practitioner knows me as a person”

Broad

array of services = “My PCP takes care of the bulk of my health care

needs”

Coordination

of care = “My PCP coordinate any care I need from the health system”

Bob

Berenson (who has authored and co-authored some very important articles on

health policy lately and headed up the PCMH review work for ACP) tells an

interesting story when he describes what it was like going around the country

assessing practices as “medical homes.”

He visited

several that met all the NCQA criteria and had all the electronic bells &

whistles. Then he visited one that didn’t have the bells &

whistles but was a very small practice with superb access, superb continuity,

and exemplified the core values of comprehensive primary care. Bob said

that the latter practice didn’t cut it as an NCQA “medical

home” but would be where he would send his parents.

Folks, the

NCQA model not only doesn’t effectively get at the core of what defines

high performing health systems, it also diverts our time, energy and money into

things that have very little to do with quality, care, and the compassion that

is the essence of what we do for our patients. As far as I can tell,

achieving “Level 3 recognition” is an expensive diversion down the

wrong road and will lead to self congratulatory delusion that somehow

we’ve created a better health care delivery system.

Gordon

From:

[mailto: ] On Behalf Of

Crowley

Sent: Friday, March 06, 2009 9:13 AM

To: practiceimprovement1

Subject: a few quick questions about your plans

for pcmh

I

have a state afp board meeting coming up, and i always feel very much the

minority when i question the validity or feasiblity of the MedicalHome, so to

arm myself (since I am often told I am alone in my feelings, and that there is

no other way), if you have a few seconds to provide me with the following data:

what

is your specialty?

what

state do you practice in? (in what state do you practice?)

do

you plan to attempt ncqa certification for a patient centered medical home?

and,

if you feel like answering, why or why not?

i

hope this is not a violation of list protocol, it is helpful for me so that, if

nothing else, i don't feel like a complete lunatic when i am surrounded by the

rest of the board. I would like to change the name of the group to

NJAPSPCMH (new jersey academy of practitioners supporting a patient

centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks,

and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 7, 2009

My kid now practices in our IMP here, and was agast that I would even download

the 50 pages on the MC. , you are totally correct that the exercise is

totally redundant and useless for our practices. Having been to MBA school, it

is obvious where this came from. It reminds me of the ABFP quality improvement

project. With my small numbers, it is difficult to get the data in the time they

are looking at, and the project is another QMi not really worth the time, since

we run our practices with lots of time to see patients, and do not rely on

others to do the work. Silly, and will not save primary care.

________________________________________

From:

[ ] On Behalf Of Brady, MD

[drbrady@...]

Sent: Friday, March 06, 2009 7:03 PM

To:

Subject: RE: a few quick questions about your plans for

pcmh

what is your specialty?

Family Medicine

what state do you practice in? (in what state do you practice?)

Virginia

do you plan to attempt ncqa certification for a patient centered medical home?

Working on it—very slowly

and, if you feel like answering, why or why not?

I fear that by just saying “bah humbug” immediately gets me dismissed as

someone not interested in moving family medicine forward, but if I were able to

qualify as a Level 3 PCMH (and I think I can), then hopefully I can work from

within the system to tell people the certification is ridiculous and will not

result in a better or more efficient system. Why?:

1) A huge portion of the PCMH is database stuff—Do you have the EMR necessary to

collect the data? Do you have protocols for how to handle the collected data? Do

you have authorized personnel who can then translate the data to the patient and

to the government?

My simple question is “how many docs enjoy doing billing?” The answer is, of

course, none. Why? It is a mind numbing, frustrating, infuriating process of

data processing. So, how many docs will do there own data collecting? Well,

none. So are we just creating an entirely new field of “chronic disease analyst”

so we can then pay someone else the extra income we are making (if we make any)

so the appropriate boxes will be checked? Well, yes. So how does having more

people between the doctor and the patient strengthen the doctor-patient

relationship and how does that impact a med student’s decision to choose family

medicine as a career?

2) The PCMH criteria are skewed toward large practices—I have to write up

protocols stating that I have written guidelines on how to treat diseases so all

the providers (which would be me) follow the same guidelines. Umm, I hope that I

am relatively consistent with how I treat my diabetics, but the protocols must

be written.

3) There is little evidence which shows incentive payments for data analysis

actually improves outcomes. This is a little scary to talk about, but there was

a study ( et al., “The Impact of Pay for Performance on Diabetes Care in

a Large Network of Community Health Centers”) which showed that P4P initiatives

lead to increased testing, but that there was little impact on the results. In

fact, overall HgbA1C went up showing that getting the data does not necessarily

mean that data will impact the patient’s life resulting in better outcomes.

Think about this for a moment. The entire argument for the patient centered

medical home is that it will save money through providing superior care, but

there is paltry evidence (that I have seen) which shows giving docs incentives

to meet a laundry list of guidelines works. This is no surprise because data

collection is not as important as a relationship in instigating change.

4) Does going through the process actually make a practice better? Not likely.

Practices which are doing a good job will likely get certified but the process

will not make them better (as alluded to). Poor practices cannot get

certified so they won’t try. Others will do what they need to do to get

certified but will not change the way they practice. This is because changing

behavior, even dysfunctional ones, is very difficult.

I always go back to the basics in such passionate discussions. Does what I am

doing improve my relationship with my patient? Having looked through the

certification process a fair amount, I do not believe getting certified does.

And, if it does not improve that relationship, then it will not succeed in

improving quality or stopping the failure of primary care to recruit new docs

into the ranks? No. So, is it a potentially dangerous distraction? Yes. That is

my great fear.

,_._,___

March 8, 2009

Suspect the PCMH would be useful for large group practices, esp those owned and operated by health systems -- these have to justify every expenditure, and having worked in 2 of them, the PCMH may be the only way that the physicians can force expenditure on quality items.

Solo or small groups owned by docs will expend resources on useful items while delivering care.

Gordon, can you convince the larger powers that be that the PCMH will not be useful for small practices; indeed the extra monies promised would only be substantial and cost effective for the larger practices and would help them pay for their additional overhead.

My perspective, out in the suburbs of Pittsburgh/Western PA

solo FP

Matt Levin, MD

a few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much the minority when i question the validity or feasiblity of the MedicalHome, so to arm myself (since I am often told I am alone in my feelings, and that there is no other way), if you have a few seconds to provide me with the following data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me so that, if nothing else, i don't feel like a complete lunatic when i am surrounded by the rest of the board. I would like to change the name of the group to NJAPSPCMH (new jersey academy of practitioners supporting a patient centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

March 8, 2009

To answer your questions:

Family medicine

Colorado

No

As others have stated more eloquently, it

will not improve the quality of care I provide to my pts, and will take mucho

time away from caring for them, with no gain to me or my pts.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

www.PinnacleFamilyMedicine.com

From:

[mailto: ] On

Behalf Of Crowley

Sent: Friday, March 06, 2009 10:13

AM

To: practiceimprovement1

Subject: a

few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much

the minority when i question the validity or feasiblity of the MedicalHome, so

to arm myself (since I am often told I am alone in my feelings, and that there

is no other way), if you have a few seconds to provide me with the following

data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered

medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me

so that, if nothing else, i don't feel like a complete lunatic when i am

surrounded by the rest of the board. I would like to change the name of

the group to NJAPSPCMH (new

jersey academy of practitioners supporting a patient

centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 8, 2009

Patients often say " doc what should I do? " I tell them that what you should be asking me is " what would you do if this were your mother? " Funny how it is a differtn answer huh?See, Berenson gets that:)

hopelessly stuck in a hotel in detroit sadly....Jean

This is a very important issue.

We have to step back and ask the question:

What are we trying to accomplish?

What I hope is that the NJAFP is trying to

help its membership practitioners remain vital contributors to their

communities by providing excellent health care for reasonable compensation.

The question “will PCMH get us

there?” is the next most important question.

Brady, Egly, & Antonucci respond very

well to this.

When we step back and look at the goal of

improved population health, improved experience of care, reduced per-capita

cost of health care, we will likely agree that a system achieving these

meaningful goals is doing a good job – it is in the words of the

Commonwealth Fund a “high performing health system.”

Such systems are founded on comprehensive

primary care.

Comprehensive primary care has certain

cardinal features:

First point of contact = “I have no

problem getting care when I need it”

Relationship over time = “My primary

care practitioner knows me as a person”

Broad array of services = “My PCP

takes care of the bulk of my health care needs”

Coordination of care = “My PCP

coordinate any care I need from the health system”

Bob Berenson (who has authored and

co-authored some very important articles on health policy lately and headed up

the PCMH review work for ACP) tells an interesting story when he describes what

it was like going around the country assessing practices as “medical

homes.”

He visited several that met all the NCQA

criteria and had all the electronic bells & whistles. Then he visited

one that didn’t have the bells & whistles but was a very small practice

with superb access, superb continuity, and exemplified the core values of

comprehensive primary care. Bob said that the latter practice didn’t

cut it as an NCQA “medical home” but would be where he would

send his parents.

Folks, the NCQA model not only doesn’t

effectively get at the core of what defines high performing health systems, it

also diverts our time, energy and money into things that have very little to do

with quality, care, and the compassion that is the essence of what we do for

our patients. As far as I can tell, achieving “Level 3 recognition”

is an expensive diversion down the wrong road and will lead to self congratulatory

delusion that somehow we’ve created a better health care delivery system.

Gordon

From: [mailto: ] On Behalf Of Crowley

Sent: Friday, March 06, 2009 9:13

AM

To: practiceimprovement1

Subject: a

few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much

the minority when i question the validity or feasiblity of the MedicalHome, so

to arm myself (since I am often told I am alone in my feelings, and that there

is no other way), if you have a few seconds to provide me with the following

data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered

medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me

so that, if nothing else, i don't feel like a complete lunatic when i am

surrounded by the rest of the board. I would like to change the name of

the group to NJAPSPCMH (new

jersey academy of practitioners supporting a patient

centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

March 8, 2009

Why hopeless in Detroit????????????

a few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much the minority when i question the validity or feasiblity of the MedicalHome, so to arm myself (since I am often told I am alone in my feelings, and that there is no other way), if you have a few seconds to provide me with the following data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me so that, if nothing else, i don't feel like a complete lunatic when i am surrounded by the rest of the board. I would like to change the name of the group to NJAPSPCMH (new jersey academy of practitioners supporting a patient centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax impcenter.org

March 9, 2009

To all,

The current system does not want to change.

The system has no incentive to change.

The whole idea of measuring non-indicators of patient wellness has been around for quite awhile and has yet not proven its worth to anyone except those promoting and invested in the current status quo.

Trying to change the system from within, I feel, is an enormous waste of time and resources, might actually end up harming more patients along the way, and only serves to bolster the " status quo. "

I only say this to strengthen my own reserve as I face mounting pressures to participate in continued nonsense that does not add any value to the doctor patient relationship.

Durango, CO

Why hopeless in Detroit????????????

a few quick questions about your plans for pcmh

I have a state afp board meeting coming up, and i always feel very much the minority when i question the validity or feasiblity of the MedicalHome, so to arm myself (since I am often told I am alone in my feelings, and that there is no other way), if you have a few seconds to provide me with the following data:

what is your specialty?

what state do you practice in? (in what state do you practice?)

do you plan to attempt ncqa certification for a patient centered medical home?

and, if you feel like answering, why or why not?

i hope this is not a violation of list protocol, it is helpful for me so that, if nothing else, i don't feel like a complete lunatic when i am surrounded by the rest of the board. I would like to change the name of the group to NJAPSPCMH (new jersey academy of practitioners supporting a patient centered medical home), but i guess that wouldn't fit on the shirt logos...

thanks, and happy friday.

tac-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.

Remember that e-mail may not be entirely secure/ MD ph fax impcenter.org

March 9, 2009

Matt – I’m working on an

article addressing this very issue & will be submitting for publication.

That’s one approach.

A second approach are the blog pieces:

http://idealmedicalpractices.typepad.com/ideal_medical_practices/

A third approach is targeted action

through SavingPrimaryCare.org – having front line folks write letters to

local papers describing the benefits of comprehensive primary care versus

jumping through administrative hoops of questionable value.

Gordon

From: [mailto: ] On Behalf Of Dr Levin

Sent: Saturday, March 07, 2009

5:21 PM

To:

Subject: Re:

a few quick questions about your plans for pcmh

Suspect the PCMH would be useful for large group practices,

esp those owned and operated by health systems -- these have to justify every

expenditure, and having worked in 2 of them, the PCMH may be the only way that

the physicians can force expenditure on quality items.

Solo or small groups owned by docs will expend resources on

useful items while delivering care.

Gordon, can you convince the larger powers that be that the

PCMH will not be useful for small practices; indeed the extra monies promised

would only be substantial and cost effective for the larger practices and would

help them pay for their additional overhead.

My perspective, out in the suburbs of Pittsburgh/Western PA

solo FP

Matt Levin, MD

a few quick questions about your plans for pcmh

I have a state afp

board meeting coming up, and i always feel very much the minority when i

question the validity or feasiblity of the MedicalHome, so to arm myself (since

I am often told I am alone in my feelings, and that there is no other way), if

you have a few seconds to provide me with the following data:

what is

your specialty?

what state

do you practice in? (in what state do you practice?)

do you plan

to attempt ncqa certification for a patient centered medical home?

and, if you

feel like answering, why or why not?

i hope this

is not a violation of list protocol, it is helpful for me so that, if nothing

else, i don't feel like a complete lunatic when i am surrounded by the rest of

the board. I would like to change the name of the group to NJAPSPCMH

(new jersey

academy of practitioners supporting a patient centered medical home), but i

guess that wouldn't fit on the shirt logos...

thanks, and

happy friday.

tac

--

Crowley,

MD

Family Medicine

Cape May Courthouse

NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

March 11, 2009

, I'm interested in what " mounting pressures " you're feeling.

On days like today, I have a hard time visualizing making your leap. While I

have grateful self-pay patients for whom I offer significant discounts, then I

have the patient today who writes the note on her 4-month-past-due bill about

how my $145 charge was too much and threatening to leave (yes!). Nevermind the

fact that she has Medicare and only $88 was allowed. Nevermind that she had to

pay only half of that as her deductible. Nevermind that I spent 40 minutes plus

significant follow up time dealing with her 6 chronic problems and associated

meds. Nevermind that she regularly calls requesting that I diagnose her acute

problems with tests ordered over the phone. Nevermind that I did 2 long med

prior auths for her in the past 2 months. Nevermind that I take home $14/hr for

putting up with her.

, did these folks disappear from your new practice, or do you have to keep

dealing with them?

Haresch

> >

> >> This is a very important issue.

> >>

> >> We have to step back and ask the question: What are we trying to

> >> accomplish?

> >>

> >> What I hope is that the NJAFP is trying to help its membership

> >> practitioners remain vital contributors to their communities by providing

> >> excellent health care for reasonable compensation.

> >>

> >> The question " will PCMH get us there? " is the next most important

> >> question.

> >>

> >> Brady, Egly, & Antonucci respond very well to this.

> >>

> >> When we step back and look at the goal of improved population health,

> >> improved experience of care, reduced per-capita cost of health care, we

will

> >> likely agree that a system achieving these meaningful goals is doing a good

> >> job – it is in the words of the Commonwealth Fund a " high performing health

> >> system. "

> >>

> >> Such systems are founded on comprehensive primary care.

> >>

> >> Comprehensive primary care has certain cardinal features:

> >>

> >> First point of contact = " I have no problem getting care when I need it "

> >>

> >> Relationship over time = " My primary care practitioner knows me as a

> >> person "

> >>

> >> Broad array of services = " My PCP takes care of the bulk of my health care

> >> needs "

> >>

> >> Coordination of care = " My PCP coordinate any care I need from the health

> >> system "

> >>

> >> Bob Berenson (who has authored and co-authored some very important

> >> articles on health policy lately and headed up the PCMH review work for

ACP)

> >> tells an interesting story when he describes what it was like going around

> >> the country assessing practices as " medical homes. "

> >>

> >> He visited several that met all the NCQA criteria and had all the

> >> electronic bells & whistles. Then he visited one that didn't have the

bells

> >> & whistles but was a very small practice with superb access, superb

> >> continuity, and exemplified the core values of comprehensive primary care.

> >> Bob said that the latter practice didn't cut it as an NCQA " medical home "

> >> but would be where he would send his parents.

> >>

> >> Folks, the NCQA model not only doesn't effectively get at the core of what

> >> defines high performing health systems, it also diverts our time, energy

and

> >> money into things that have very little to do with quality, care, and the

> >> compassion that is the essence of what we do for our patients. As far as I

> >> can tell, achieving " Level 3 recognition " is an expensive diversion down

the

> >> wrong road and will lead to self congratulatory delusion that somehow we've

> >> created a better health care delivery system.

> >>

> >> Gordon

> >>

> >> ------------------------------

> >>

> >> *From:* [mailto:

> >> ] *On Behalf Of * Crowley

> >> *Sent:* Friday, March 06, 2009 9:13 AM

> >> *To:* practiceimprovement1

> >> *Subject:* a few quick questions about your plans

> >> for pcmh

> >>

> >> I have a state afp board meeting coming up, and i always feel very much

> >> the minority when i question the validity or feasiblity of the MedicalHome,

> >> so to arm myself (since I am often told I am alone in my feelings, and that

> >> there is no other way), if you have a few seconds to provide me with the

> >> following data:

> >>

> >> what is your specialty?

> >>

> >> what state do you practice in? (in what state do you practice?)

> >>

> >> do you plan to attempt ncqa certification for a patient centered medical

> >> home?

> >>

> >> and, if you feel like answering, why or why not?

> >>

> >> i hope this is not a violation of list protocol, it is helpful for me so

> >> that, if nothing else, i don't feel like a complete lunatic when i am

> >> surrounded by the rest of the board. I would like to change the name of

the

> >> group to NJAPSPCMH (new jersey academy of practitioners supporting a

> >> patient centered medical home), but i guess that wouldn't fit on the shirt

> >> logos...

> >>

> >> thanks, and happy friday.

> >>

> >> tac

> >>

> >> --

> >> Crowley, MD

> >> Family Medicine

> >> Cape May Courthouse NJ

> >>

> >> Patients, please allow up to 48 hours for response. If you are having an

> >> urgent problem please go to the emergency department or call 911. If you

> >> have a problem or question that can't wait 48 hours, or you have not

> >> received a timely response, just call the office at 465-0882.

> >>

> >

> > --

> > If you are a patient please allow up to 24 hours for a reply by email/

> > please note the new email address.

> > Remember that e-mail may not be entirely secure/

> > MD

> >

> > ph fax

> > impcenter.org

> >

>

March 11, 2009

,

Let her go and advise her to let the door hit her in the butt on

the way. She is one of those people that thinks the government should

cover it all and she should get everything for nothing.

My staff and I were talking about this today because I am

cleaning house. Yes, I will work with people without insurance. I

offer discounts. But people with insurance need to pay their

copays. I don’t care if it’s $5/month but make an

effort. Don’t keep ignoring my bills. Venting. We

actually had one woman say she was planning on paying on her next visit.

But she hasn’t been in for 15 months. Then says she doesn’t

have a checking account? How does she pay her other bills? Come on.

I am not a “no insurance” practice so I know you

aren’t asking me the question but I offered an opinion anyway.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Haresch

Sent: Tuesday, March 10, 2009 10:16 PM

To:

Subject: Re: a few quick questions about your

plans for pcmh

, I'm interested in what " mounting

pressures " you're feeling.