There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.
In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:
Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients” (1). Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967. In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.
Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care. (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011. They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.” (3)
And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.
Increasing access to insurance via exchanges and Medicaid expansion is zero sum game unless accompanied by increased access to primary care services. That was a key lesson learned in Massachusetts’ reform circa 2006. And these three items from last week’s news suggest it’s getting deserved attention but no further clarity.
It’s obvious to all that a new solution is needed for primary care. But exactly what it should be is a vigorous debate. Our intramural conflicts are getting us no closer to a resolution. Consider…
- Hospitals and health insurers are competing to employ community-based primary care physicians in the event that capitated payments become the dominant payment model. So private practices of primary care are fast becoming extent.
- Primary care physicians and specialists are at odds over who owns their patients. Some specialists—oncologists, cardiologists, obstetricians, rheumatologists, psychiatrists and others—claim dual citizenship in primary care and specialty medicine.
- Primary care physicians—general internists, family physicians and pediatricians– are waging war with specialists about how they’re paid. The Resource-based Relative Value Scale methodology used by Medicare and other payers to set reimbursement shortchanges “cognitians” in favor of “procedurists”—not surprising since the majority of physicians who weigh in on the model are specialists. (4)
- And primary care physicians are fighting a holy war against advanced practice nurses and nurse practitioners that seek expanded scope of practice privileges, and non-conventional therapies (naturopathic medicine, alternative health, et al) believing they sell snake oil.
So finding a solution to accommodate increased demand for primary care services seems mired in the politics of the professions themselves. What’s the answer?
To begin, the Affordable Care Act, though criticized, offers some important starting points…
- Increased pay for primary care physicians: PCPs who see large numbers of Medicaid patients get paid at the higher rate paid by Medicare (just extended one year)
- Increased supply of primary care services: additional medical residences in primary care, recognition of federally qualified health centers as medical homes, and additional training for nurses and allied health professionals
- Stronger positioning as gatekeepers in demonstrations and pilot programs: the ACA’s patient centered medical home, accountable care organization, annual physicals for Medicare enrollees and incentives for employer wellness programs all require strong primary care front doors.
But these do not go far enough. Otherwise, the ranks of those enrolling in medical and nursing schools to serve in primary care roles would accommodate growing demand. But they’re not.
The future of primary care is not a repeat of the past: it is not a replay of Marcus Welby, MD.
Primary care 2.0 will be provided by teams of nutritionists, psychologists, dentists, ophthalmologists, geneticists, health coaches, nurses, and physicians who manage a population of several thousand assigned patients, coordinating their care, managing their access to and use of specialty and alternative health services over a long period of time. Teams will compete for contracts. They will be paid on a capitated basis, with bonuses for clinical outcomes, user satisfaction, safety and savings against historic trends. Incentives, and risk, will be born by the team. Clinical judgement will be supported by decision support technologies and every patient connected by mobile health technologies used to prompt adherence to customized self-care plans. Physicians will contribute their domain expertise as members of the team, not necessarily as captains of every team so other competencies are better integrated in care management. And results will be constantly measured against historic trends and best practice benchmarks with easy access by consumers and employers.
Primary 2.0 is a dramatic change from the status quo. How would we get there? Beyond what’s in the ACA, it requires four actions requiring commitment by policymakers and industry leaders:
1-Revamp “medical education” in primary care to a team based model. A six-year post-high school program for all primary care clinicians—nurses, physicians, and allied health professionals seeking careers in primary care—could replace the costly structure 8-year program in place today. Placement in the program would be based on competency-based skills assessed in the first two years of the program. Acceptance into certified Primary Care 2.0 training programs featuring the team-based model would carry a full scholarship for 4 years of classroom and site-based training. Hospitals, health plans, or employers in addition to the federal government plan would pay scholarships, and contracts for service to scholarship awardees linked to measurable competency attainment and maintenance assessed annually. To create the workforce necessary to Primary Care 2.0, a new, streamlined, team-based approach to their education linked to life-long competency-based learning is needed.
2-Create a liability safety net in primary care. The risks associated with insuring accuracy in diagnosing and appropriateness in treating populations with a myriad of signs, symptoms, risk factors and co-morbidities would be mitigated in the Primary Care 2.0 model by (1) binding hold-harmless arbitration for teams funded through malpractice premiums and victims funds, and (2) public access to Primary Care 2.0 teams’ clinical algorithms and outcomes used to manage their populations. The expense for unnecessary tests and procedures to defend against liability claims exceeds $50 billion annually; premiums for liability and victim awards in Primary Care 2.0 could be less than $20 billion. Participants in teams would be protected from individual risk provided their team is vigilant about its adherence to team-assigned roles and competencies and policies, procedures and data is evident to demonstrate discipline in oversight. Creating a liability safety net is essential to Primary Care 2.0 risk taking and its savings could fund acceleration of its implementation.
3-Formalize and equip the primary care gatekeeper system. Millennials will support Primary Care 2.0; seniors less so. The generational preference about having “my doctor” is gradually giving way to consumer choices shaped by access, costs and the branding of an organization’s approach to medical care. So policy makers are on safe ground to institutionalize a Primary Care 2.0 gatekeeper system not because it’s desirable to seniors, but because its value proposition in managing costs while optimizing quality and safety can be readily demonstrated. Requiring enrollees in Medicaid, Medicare, military health and federal health enrollees to maintain an active relationship with a primary care team via capitation is a start. And funding meaningful use 2.0 and 3.0 investments for these teams would jumpstart their acceptance by clinicians. Ultimately, federal and state policies that establish gatekeeper status for appropriately operated Primary Care 2.0 teams would be transformative.
4-Promote the value proposition for primary care 2.0: Like Rodney Dangerfield, primary care has a chip on its shoulder, especially primary care physicians who feel little respect from their peers. A national campaign to educate consumers and employers about the value proposition of Primary Care 2.0 would be a necessary investment.
Last week, the nightly news focused on the Ukraine’s unrest. The other unrest is in primary care. A transformative solution is needed. Perhaps Primary Care 2.0 might be a start. Let’s discuss solutions.
(1) AAP Principles Concerning Retail Based Clinics, February 24, 2014
(2) The Agency for Healthcare Research and Quality (AHRQ) defines the medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes: comprehensive care, patient centered, coordinated care, accessible services, quality and safety. (AHRQ.gov)
(3) Mark W. Friedberg, MD, MPP; Eric C. Schneider, MD, MSc; Meredith B. Rosenthal, PhD; Kevin G. Volpp, MD, PhD Rachel M. Werner, MD, PhD “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care JAMA. 2014;311(8):815-825.
(4) The Resource-based relative value scale (RBRVS) is used by Medicare and private payers to determine how much money medical providers are paid. It assigns procedures performed by a physicians and other medical providers a relative value adjusted by geographic region that is multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment calibrated to physician work (54%), practice expense (41%), and malpractice expense (5%).