Saturday, August 16, 2008

Primary care, medical home - Profound Primary Care Paradigm Shift Underway

This is my 600th blog. This fact may indicate: a) I have a bad case of verborrhea, b) I have something to say. I pray it’s the latter. In any case, this blog may be one of my more important and influential ones. This self-righteous assessment assumes what I say will be correct and will come to pass.

Profound Changes in Attitudes

Something profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place..

Signs of Paradigm Shift

Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from failing through the cracks. We must stop wasting time and resources for patients and the system as a whole.

The problem of the U.S. system isn’t quality. It’s timely access to primary doctors who oversee care. And it’s overuse of specialty services. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.

What’s Driving the Paradigm Shift

• Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Technology and Strategic Initiatives, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.

• A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.

• The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real...

• New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 real clinics, 500 worksite clinics, and roughly 3000 urgent care facilities.

• The physician empowerment movement is growing. The Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care., a physician social networking site, has 75.000 members and will soon issue an “Open Letter to the American public signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.

A new primary care paradigm is upon and will fundamentally change how the U.S. delivers care.

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