Does Primary Care Need To Be Retooled?

Joe Cantlupe, for HealthLeaders Media , March 14, 2013

The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be "preferentially" scheduled to facilitate more efficient visits that may include group educational programs, they write.

Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.

It's no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. "Various organizations have built a whole care model for those people," Porter says.

He pointed out some examples, including the Commonwealth Care Alliance , which includes multidisciplinary teams and home visits. Others having integrated delivery care, where primary care and specialists work hand-in-hand, include CareMore, Intermountain Healthcare, Cherokee Health System, and the Department of Veterans Affairs.

To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a "total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients."

While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. "We've got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero," Lee says of Partners. "It's not anyone's job right now. Therefore, no one does it in a systematic way."

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1 comments on "Does Primary Care Need To Be Retooled?"

George Anstadt MD FACOEM FACPM (3/14/2013 at 9:37 PM)
The Lee /Potter proposal: subjugate primary care physicians, and the patient's interests that the primary guards, using "market share" mechanism coupled with a "Strategic Frameworks" panacea; specialists and the system know best, or will know best as soon as Lee can assign someone the task of value guru. Further fractionate and specialize. The system with the most specialist wins. The patient centered notion is wrongheaded. In fact, as you look for value in the real world, the nations with the highest ratios of primary to specialty care are the best. For example, it is widely recognized that the US does 10x greater spine surgery than other nations, without any observed benefit in terms of spine health, but at far greater cost. No health status benefit / very high spine surgeon incomes + hospital charges + device prices = poor value. Lee contends that no one in his system is focused on health care value; yet, the primary is trained to provide value, which is best achieved by preventing disease in the first place, and also by finding simple solutions rather than tertiary care for problems. The US healthcare system impedes good primary care, especially prevention, with both financial disincentives and procedural barriers; never-the-less, if Dr. Lee were to examine the outcomes of his primary care doctors at the individual physician level, he would find a dedicated and caring minority who still do the right things, despite the difficulties, and as a result are getting much better health status outcomes, e.g. fewer MI, less new onset diabetes, etc., which save our healthcare system huge amounts of money. These are the overlooked folks in his system who are trained to provide value, and who ARE providing value. He should identify them, celebrate the increased health and decreased cost (value) that they are providing to our healthcare system, reward them financially, and learn from them. Their best practices should be facilitated with administrative and technology investments, and then shared them with the other primary care providers, which will not be a hard sell. Most of these primary care docs are longing to do these right things, but need encouragement, tools, time and financial incentives. Trouble is, insurance doesn't reward value, only encounters and procedures. So, Lee will have to figure out how to get paid for value, or just keep hiring more guys who do high revenue procedures, and push his primary care docs to encounter more people per hour. Our medical students are watching. Do we want more spine specialists and even fewer primary care docs?




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