Saturday, January 17, 2009

Primary care - Three Visions: Dissolution, Restoration, or Transformation of Primary Care

I see three primary care visions.

- One is that primary care has “fallen off the cliff,” has hit bottom, will never recover, and will be replaced by armies of nurse doctors, nurse practitioners, physician assistants, and computer-aided consumers practicing self-care.

- Two is that primary physicians are in such demand that their salaries, benefits, and empowered organizations will restore them to primacy and will begin to attract medical students back into their ranks.

- Three is that primary care drive medical homes will transform medicine through renewed personal patient physician relationships leading to preventive care and coordinated, comprehensive care with a resulting renaissance of primary care.

Examples of Vision

What follows are examples of how these visions are being pursued by organizations and individuals.

ProHealth Physicians, Inc, is a successful 232 member provider group (185 primary physicians, 5 or 6 specialists, and the rest NPs and Physicians Assistants). It is headquartered in Farmington, Connecticut. ProHealth is 10 years old. Primary care doctors are its owners. Over its ten year history, it has enhanced its owners’ incomes, set up diagnostic, imaging, laboratory, and other centers across Central Connecticut, and remained free from hospital control. It recently contracted with AllScripts to install EMRs in doctors’ offices. Its average market share is 18% in communities in which its practices are located. It seeks to restore primary care to its rightful role as a convenient access point for consumers, to set standards for its owners, who remain largely autonomous in their practices, and to improve care. It harbors no illusions that it will transform U, S health care into a primary care dominated system. But it thinks enhanced incomes and systematic pay-down of medical education loans will attract new primary care doctors. This type of organization could be said to belong to the Grow Big, or Die school, namely, that primary care doctors have to be in organizations with sufficient scale to have the capital, ideas, and infrastructure to make a difference and to thrive.

The Physicians’ Foundation is a non-profit organization. It was formed in 2003 as the result of a class action settlement between state and local medical societies and major health plans. The health plans agreed to fund two physician foundations, which later merged into one foundation. The Foundation encourages physician practice improvement through grants and physician surveys. It has issued grants over $20 million to physician organizations to help them improve care, often through better use of EMRs and IT. Its IT experience has been most physician organizations lack the structure, skills, and incentives to adopt and to adapt to EMRs. Doctors are too swamped with heavy patient loads, insufficient reimbursements, growing overheads, and entangling and suffocating rules, regulations and managed care hassles. In a national survey of 270,000 primary care doctors and 50,000 specialists who often practice primary care, the Foundation learned that the primary care physician are in dire straits, with over 78% saying a primary care shortage exists, and as many as 50% thinking of retirement, alternative practices or careers, with significant numbers expressing disillusionment, demoralization; and most not recommending medicine as a career. The survey results were announced on November 18, 2008 and received wide media exposure. The Foundation hopes to sway public and policymakers’ opinions so that steps will be taken to restore primary care through various measures such as education support, forgiveness of loans, and revamped primary care reimbursement. Its view is that the time is growing late to save primary care, and steps must be taken now.

The Patient-Centered Primary Care Collaborative - This organization is a mix of leading national primary care organizations, consumer groups, patient quality organizations, health plans, labor unions, hospitals, and others. It has 300 members. Its mission is to make primary care-led medical homes operating as teams the centerpiece of U.S. health care. These teams will stress prevention, electronic information linkage, and coordinated, comprehensive care. Paul Grundy, MD, director of health care transformation at IBM, serves as chairman. Through his leadership, national primary care organizations – the American Association of Family Physicians, American College of Physicians, American Pediatric Academy of Pediatrics, and the American Osteopathic Association – have developed joint principles for the Medical Home, which stresses a team-based approach to primary care with a personal physician at its core. Grundy envisions a series of medical homes across America. As in other countries, these homes or their equivalents will presumably lower costs, improve quality, and produce better outcomes with greater satisfaction among patients and doctors. Grundy’s model for care is Denmark, where

o primary care doctors are paid through a blended three part payment system – fee-for-service, a capitation fee for managing their panel of patients, and bonuses for responsive patient-centered services (same day appointments, and prompt responses to emails and phone calls),

o all doctors and hospitals can communicate through a physician-developed electronic medical record system, where all patients know the name of their personal physician,

o primary care doctors and salaried specialists have equivalent incomes and prestige and status.

Grundy’s view is that “comprehensivenists,” primary care doctors, deserve just as much income and status as “partialists,” i.e. specialists. He maintains that America already has a single payer system, consisting of CMS-RUC (Centers for Medicare and Medicaid Services + the specialty dominated Reimbursement Update Committee), and that this structure will have to be changed if an effective primary care transformation of American medicine is to occur. He says hospitals, specialists, and health plans recognize, or at least give lip service, to the need for this transformation, but it will take time, perhaps even decades, and robust federal and state support to resolve conflicts so that the transformation can happen.


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