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New Health Affairs Issue: Reinventing Primary Care



May 4th, 2010
by Chris Fleming

Bold changes are needed in how the United States delivers and pays for primary care if the key goals of national health reform are to be achieved, according to the May issue of Health Affairs. This thematic issue of the journal, released today at a National Press Club briefing, examines the crisis facing the U.S. primary care system as well as promising solutions for reinventing primary care.  Building a state-of-the-art primary care system, the issue concludes, is critical to achieving better health care, better value for the dollars spent, and expanded access for the tens of millions of Americans who will gain insurance coverage over the next few years.

The United States faces a well-known shortage of primary care providers, but recruiting more physicians, nurse practitioners, physician assistants, and others is only a part of what’s needed.  As Mark W. Friedberg and colleagues at the RAND Corporation suggest, the entire system needs to shift toward a primary care orientation to improve health outcomes.  The “horribly broken” primary care system that we have now is plagued by underinvestment and misaligned incentives, says Susan Dentzer, Health Affairs’ editor-in-chief. Dentzer says health reform offers the opportunity to reinvent primary care and rapidly move it into the twenty-first century. “Primary care is maddeningly stuck in a bygone era. Practitioners are typically paid only for in-person ‘visits’ when e-mail consultations and telemedicine could readily handle many patient complaints,” she writes. 

The May issue of Health Affairs is funded by the United Health Foundation, California HealthCare Foundation, CVS Caremark, ABIM Foundation, and American Academy of Physician Assistants. 

Primary Care – Where We Are and How Far We’ve Come 

Several studies in this issue review the state of primary care in the United States and reflect on the lessons that history – and a tradition of reinvention – offer about reform: 

  • An overview of the current landscape of U.S. primary care from Thomas Bodenheimer of the University of California, San Francisco, and Hoangmai H. Pham of the Center for Studying Health System Change quantifies anticipated workforce shortages in primary care, highlights the geographic maldistribution problem, and offers  short- and long-term solutions to improving access.
  • It is currently difficult to recruit physicians to primary care, due in large part to the considerable pay gap between specialists and primary care physicians. A study by Bryan T. Vaughn and colleagues at Duke University underscores the challenge of overcoming that gap, noting that a primary care physician could earn $3 million less over a career than a cardiologist – a disparity that significantly influences the career choices of medical students.
  • Primary care was born out of tension with other forms of medical care, and the same external forces that shaped past systemic transformation will do so again, observes Joel D. Howell of the University of Michigan.  “The question is not, ‘Will primary care be reinvented?’ but rather, ‘How?’” he says.  
  • A look back at trends in medical practice redesign over the last four decades can offer lessons for how to implement new models of care, such as the medical home. Charles M. Kilo of the Oregon Health and Science University and John H. Wasson of the Dartmouth Medical School emphasize that the medical home model is not yet tested by time, and that periodic evaluation of its progress during implementation will be important. 

Medical Homes:  Delivering Better Care for Less

Recent health reform legislation handed the U.S. Department of Health and Human Services the authority to test out the patient-centered medical home. Several studies examine this model, widely regarded as the most promising one for reforming primary care delivery: 

  • To succeed, the patient-centered medical home must have four essential elements, say Daniel Fields, a law student at Harvard University , Elizabeth Leshen, a student at the Massachusetts Institute of Technology, and Kavita Patel, formerly of the White House Office of Public Engagement. These elements are: dedicated care managers to direct patient care, tools to manage performance and track outcomes, payment incentives to lower cost, and round-the-clock medical advice.
  • Paul Grundy of IBM, Senator Kay R. Hagan (D-N.C.), Jennie Chin Hansen, the outgoing president of AARP, and Kevin Grumbach of  the University of California, San Francisco, make the case for primary care reform  for private purchasers, government, consumers, and clinicians. They argue that broad stakeholder support will be critical for primary care reform to succeed.
  • Robert Reid of Group Health Research Institute and colleagues share results from a medical home model developed by the Seattle-based Group Health Cooperative.  A study comparing more than 7,000 patients at the medical home with more than 200,000 non-medical home patients showed that access to a medical home led to 29 percent fewer visits to the emergency room and 6 percent fewer hospitalizations.
  • There is no single best way of paying for care in medical homes as of yet, but Katie Merrell of the Center for Health Research and Policy and Robert A Berenson of the Urban Institute detail promising paymentmethods, including an approach that features both fee-for-service and capitation or fixed payment for all services.
  • Medical homes must overcome some key challenges to be successful, including finding ways to fund the early start-up phase, according to a study by Bruce E. Landon of the Harvard Medical School and colleagues.

Primary Care Reform Relies on Teamwork, Management Skills

Reforms of the primary care system almost certainly will demand new models of care, including the creation of primary care teams and expanded roles for nonphysicians like nurse practitioners and physician assistants. New studies suggest that such team-centered care represents a fundamental shift in delivery, one that has the capacity to handle more patients yet still deliver high-quality care.

  • Most physicians lack the skills to manage teams and coordinate care under the new models of primary care. Richard M.J. Bohmer of the Harvard Business School says that medical schools and residency programs must start training physicians to be managers if reform efforts are to succeed.
  • The United States will face a shortage of 46,000 physicians by the year 2025. Mary D. Naylor of the University of Pennsylvania and Ellen T. Kurtzman of George Washington University argue that registered nurses should be tapped to fill that void since nurses already provide hands-on bedside care in a variety of settings and are well equipped  to deliver certain kinds of primary care. Joanne M. Pohl of the University of Michigan and her colleagues argue that while physicians are pushing for bigger salaries and a lead role in managing new models of care, nurse practitioners are already highly skilled at managing teams. The authors call for lifting state restrictions that prevent nurses from practicing to the extent that their training and licenses warrant.
  • Physician assistants could bolster the workforce in the primary care field, but only if a pay gap between those who work in primary care and those who work in medical and surgical specialties  is addressed, according to Perri A. Morgan of the Duke University Medical Center and Roderick S. Hooker of the University of North Texas Health Sciences Center and the Department of Veterans Affairs in Dallas. Their new analysis shows that the number of physician assistants in specialty fields has been growing rapidly, probably because of higher pay in these fields.
  • Pharmacists must be members of any team providing primary care, according to Marie Smith of the University of Connecticut and her colleagues. Pharmacists often catch medication mistakes made by other members of the primary care team, mistakes that can lead to costly medical complications, the authors say.
  • Stephen C. Shannon of the American Association of Colleges of Osteopathic Medicine and colleagues point out that a loan forgiveness program might get more osteopathic physicians to pick careers in primary care. 

Practice Profiles:  E-Referrals, Core Teams Provide Better Quality

This issue of Health Affairs includes a series of Practice Profiles, case studies of promising approaches to delivering primary care across the country. Highlights:

  • Christine A. Sinsky of the Medical Associates Clinic and Health Plans and colleagues paired physicians with nurses into core teams that delivered primary care in a novel way.  Nurses focused on prevention of chronic conditions, and physicians spent more time treating or managing health problems. The authors found that such teams often provided better, more coordinated care.
  • In 1991, Quad/Graphics, a large, Wisconsin-based printing firm, started QuadMed, an in-house health care provider focusing on prevention and wellness.  Its continuing success, writes QuadMed’s president, Raymond Zastrow, and colleagues is due to the integration of benefit design and a focus on patient-centered, prevention-oriented primary care, delivered on site.
  • Access to specialist care is a common barrier for safety net clinics trying to deliver high quality care to the poor. To overcome this barrier, Alice Hm Chen at San Francisco General Hospital and colleagues developed an electronic referral system that reduced wait times for nonurgent visits for the poor and uninsured by up to 90 percent during a six-month period.
  • Seattle’s Qliance Medical Group is a direct primary care practice.  Patients pay a modest age-adjusted monthly fee for unrestricted, comprehensive care, with access to providers 24/7.  This direct care medical home offers longer patient visits, minimizing referrals to specialists and hospitals, for which patients must purchase separate insurance coverage.  Qliance’s CEO, William N. Wu, and colleagues report that in its first two years of operation, the practice’s patient base has grown to almost 3,000 patients, with no provider turnover.  
  • Barbara S. Fischer at the Department of Public Health in Chicago and colleagues implemented an electronic system to request and track specialist or diagnostic testing for uninsured and Medicaid patients. Wait times dropped from an average of three months to 5.5 days. 
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1 Response to “New Health Affairs Issue: Reinventing Primary Care”

  1. Malaika Stoll Says:

    What is the best way to pay for Primary Care?

    The newly legislated Center for Medicare and Medicaid Innovation calls upon clinicians, hospitals, payers, employers, State governments and others to help answer this question. We need to collaborate with one another, to decide which payment mechanisms are the most promising, and then we need to try them out. Here are some potential ways to improve how we currently pay (Fee for Service) physicians and providers:

    1. Fee for Service Hybrids

    In the Pennsylvania Chronic Care Initiative, a “hybrid” model—common to Patient Centered Medical Home pilots—is being implemented. This relies primarily on existing Fee for Service rates, and adds an additional per member per month, based on demonstrating care management and achieving NCQA medical home recognition. This system has been shown to be an improvement over FFS:

    “A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes .”

    FFS remains the predominant method of reimbursement. Visit or encounter based payment, some argue, leads to the “hamster wheel” effect, resulting in lower patient and physician satisfaction, and in definitions of physician productivity that lose sight of the goal of healing.

    2. Group Health-like models. When primary care physicians are taken off the hamster wheel—as achieved in Group Health — and are paid reasonable salaries for providing accessible care to manageable patient panels, quality of care improves and savings are recouped downstream with decreased unnecessary utilization. Patients are healthier and physicians are more satisfied. In this model, patients have excellent access to care through telephone and email contact with physicians.

    3. Other hybrid models

    The advantage to a hybrid model is that it balances incentives. In a pure Fee for Service system, there is incentive to provide more, not better care. In a capitated system, where physicians are paid a set amount per patient that they take on, there may be incentives to exclude sicker patients who require more care—but for whom the reimbursement is the same as for a healthy patient. Payment for performance or quality of care is theoretically the most ideal, but can be difficult to define and implement fairly.

    Capital District Physicians Health Plan (CDPHP) is a not-for-profit health plan in New York . In one year of an intensive payment reform pilot in three primary care practices, they saw improvements in quality of care, patient satisfaction and provider satisfaction. Costs of initial investments were recouped from downstream savings, and their data suggests the potential for significant cost-savings. Based on the results of the first year, they are expanding their pilot from 3 practices to 21 practices. Their hybrid model is based on:

    • Risk adjusted Base Capitation. Conversion of fee for service payments into a base pay, that was then further adjusted based on characteristics of patient population. Salaries were increased by approximately $35,000 per year

    • Bonus of up to $50,000 per year based on three elements:

    A. Patient satisfaction (survey)
    B. Effectiveness (Quality–HEDIS)
    C. Efficiency (decrease in selected admissions and ED visits)

    • Fee for service for certain procedures/services. Total amount of salary that comes from FFS is approximately 10%.

    4. Community Health Teams

    Vermont Blueprint for Health is a state-wide initiative to transform healthcare. One aspect of this plan involves supporting Community Health Teams. All payers in the state directly support these interdisciplinary teams—comprised of health educators, public health and mental health specialists and care/case managers. Teams are formed to meet the needs of communities, and are designed to link directly with primary care practices. The new Federal healthcare legislation provides for support for this type of team. Also part of the Blueprint model is a payment reform mechanism, a FFS hybrid based on NCQA standards—similar to that of Pennsylvania.

    5. Value Sharing.

    Engaging payers for sustainable change requires that they realize cost savings as a result of funding that they provide for pilot activities. Engaging providers for sustainable change requires that they also share in these cost savings to offset losses due to decreased admissions, resource utilization and physician productivity. Value Sharing requires that savings generated for payers as a result of decreases in ED visits, inpatient admissions and overall utilization will be shared with practices and/or provider networks. Value sharing supports movement towards becoming an Accountable Care Organization (ACO).

    6. Care Management and Continuity codes

    Within FFS, physicians could code for care management activities done at the time of a visit. More radical, would be to develop systems whereby physicians could bill for email and phone call contact with patients as a part of care continuity.

    7. Just Pay Primary Care More…

    We await a 10% Medicare increase for Primary Care. By narrowing the specialist-primary care salary gap, we could improve access to primary care, decrease over-utilization and promote higher value care. Could it be just this simple?

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