The World Health Organization (WHO) has issued its World Health Report of 2008 and strongly urged countries to act on robust evidence that ready access to primary care services forms the core of a rational, well-run health system. The title of the report underscores the urgency of its message: Primary Health Care — Now More Than Ever. The report commemorates the 30th anniversary of the Alma-Ata (Kasakhstan) International Conference on Primary Health Care. The conference launched a worldwide campaign to underscore the importance of primary care and placed the WHO’s watchwords, “Health For All,” on the international political agenda.
The WHO’s report highlights diverse country experiences — some positive, many less so — of primary care. It describes countries that took their inspiration from the Declaration of Alma-Ata, such as Fiji and Madagascar, and others that predated this landmark statement, such as France’s country doctors and Cuba’s neighborhood clinics. Some countries — New Zealand being a prime example — have revitalized their primary care approach while others are considering ways to improve access to primary care services.
By contrast, the WHO report barely mentions the United States, although there are some hopeful glimmerings that an array of influential public and private interests are awakening to the critical importance of expanding primary care services as part of any effort to bring greater rationality to the delivery of health care in this country. While formidable challenges certainly remain, recent actions by federal and state governments and private-sector activities have elevated the importance of practitioners of primary care. The major focus has been in promoting the concept of a “medical home” on which patients could rely to help them navigate an exceedingly complex and uncoordinated delivery system.
A medical home is usually a physician-directed practice–although advanced practice nurses serve in such settings, particularly in rural areas–that provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.” As Bob Berenson and colleagues noted recently in Health Affairs, there is hope that an increasing number of primary care physician practices, serving as medical homes, can provide a source of confidence, advocacy, and coordination for patients as they encounter the disconnected parts of the delivery system.
The “Medical Home” Concept: Generating Enthusiasm …
In response to a mandate in the Tax Relief and Health Care Act of 2006, the Centers for Medicare and Medicaid Services (CMS) is developing a medical home demonstration to test the validity of the model over the next three years in eight states. Congress directed CMS to use the medical home demonstration to “redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations.”
In addition to congressional action, a total of 108 bills that mention the term “medical home” have been introduced in legislatures in 26 states and the District of Columbia, according to the American Academy of Family Physicians. Another sign of interest in Washington, D.C., is a series of meetings on the medical home model sponsored by the National Health Policy Forum. Its participants include professional staffers of members of Congress, executive branch agencies, and representatives of private interest groups.
In the private sector, Fortune 500 companies led by IBM have launched programs with large private health plans that recognize the value of the medical home model for their employees. In a recent article, three physicians — IBM executives Martin Sepulveda and Paul Grundy and academic researcher Thomas Bodenheimer — underscored the important role that employers could play in building a stronger foundation of primary care services.
In addition, a coalition of more than 200 large employers, health plans, consumer groups, labor unions, hospitals, medical groups, and others have joined to form the Patient-Centered Primary Care Collaborative. Its central purpose is to develop and advance the medical home model. In a new survey conducted by the PCPCC, Harris Interactive found that support for the health care plans proposed by the two presidential candidates surges when the patient-centered medical home model is included.
One of the most influential organizations that has joined the PCPCC is AARP, which has some fifty million members who are age fifty or older. In an interview I conducted, John Rother, group executive officer of policy and strategy for AARP, said: “Primary care is key to more effective and efficient delivery or services, especially for individuals with multiple chronic conditions. We support changes in physician reimbursement that will generate a more appropriate mix of physicians going forward.”
… But A Consensus Definition For “Medical Home” Is Lacking
When Health Affairs turned to developing a thematic issue on delivery system innovation and issued a call for abstracts, a number of the most interesting proposals turned on the prospects for the medical home model — both its promises and its challenges. In the lead paper, Berenson and colleagues acknowledge that although there is no agreed-upon definition of the model, four major medical organizations (American Academy of Family Practice, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association) have achieved a consensus on a set of principles of a “patient-centered medical home.”
Most importantly, Berenson and colleagues point out that because of the political and professional challenges that would arise around efforts to restructure Medicare physician fee schedules, the medical home may be an alternative way to recognize and support primary care activities. These would be activities and services that are not considered to be part of the evaluation and management codes that qualify for reimbursement under standard Medicare and private-payer payment policies. As Berenson and colleagues note: “Designating a medical home eligible to receive supplemental payments provides a potential way around the zero-sum, budget-neutral mindset that governs how fee schedules are set and that works against primary care.”
In its 2008 recommendations to Congress, the Medicare Payment Advisory Commission (MedPAC) underscored its support for recognizing through an extra monthly payment those services that physicians who practice in a medical home provide to Medicare beneficiaries. In its June 2008 report, MedPAC said: “In addition to receiving payments for the Medicare-covered fee schedule services they provide, qualifying medical homes would receive monthly payments for medical home infrastructure and care-coordination activities. .. .Beneficiary cost sharing would not apply to these medical home monthly fees.” Richard Baron and Christine Cassel recently called for new payment approaches that better reflect the value of primary care.
There are a variety of hopeful signs that primary care services delivered through medical homes or otherwise may be revalued; however, the message has not reached many graduating medical students, and because many of them leave these schools heavily in debt, who could blame them? The practice incomes of primary care physicians are half or less of those of doctors who pursue most medical specialties. Beyond the financial dimension, many young doctors favor medical careers that feature more controllable lifestyles and the greater prestige that usually comes with practicing a specialty.
Over the past decade, all of these considerations have translated into a lessening of interest in primary care among graduating medical students. The number of resident training positions in family medicine that have been filled has decreased precipitously among graduates of U.S. medical schools. Data reported by the National Resident Matching Program showed that in 1997, of 3262 training positions offered in family medicine, 2,905 or 89% were filled — 71.7% by graduates of U.S. medical schools. In 2008, of the 2,654 positions offered to students seeking advanced training in family medicine, 2,404, or 90.6%, were filled but only 1,172, or 44.2%, by graduates of U.S. schools. Many of the other family medicine positions were filled by graduates of foreign medical schools. Many foreign-trained physicians must overcome cultural and language differences to become successful primary care doctors in the United States. The composition of the physician work force is a subject closely tracked by Health Affairs and by other organizations such as the Medical Education Futures Study, an initiative funded by the Josiah Macy Jr. Foundation and headed by Health Affairs Contributing Editor FitzHugh Mullan.
As the new WHO report documented, the United States is hardly alone in addressing ways to promote a more robust system for the delivery of primary care services, and most of the countries around the world confront these challenges — even others that rank among the advanced industrialized nations. For example, a recent seven-country survey depicted a time of extensive global experimentation in the redesign of primary care services.