Tuesday, August 10, 2010
Saving primary care: Is anyone home?
The Patient Protection and Affordable Care Act (aka "Health Care Reform") signed by President Obama in March will revolutionize primary care in the United States. By 2014 tens of millions of uninsured people will "enter" the system by being granted insurance, either through expansion of the Medicaid program or through mandated purchasing of insurance via state pools or the private market.
This alone will have a profound impact, straining the capacity of our already frayed system. Therefore, embedded in the law are funds to encourage growth and improvement in primary care: Incentives to encourage graduates to enter primary care fields (family medicine, internal medicine, and pediatrics) and practice in underserved areas (through scholarships and loan forgiveness), and money to re-format the way that primary care is practiced and paid for.
The most prominent example of primary care restructuring is something called the patient-centered medical home (PCMH). Currently a national "demonstration" project is underway to show us that the PCMH model is a sustainable way forward. The PCMH promises nothing less than greater access to primary care, delivered with improved quality and safety, better data capture and analysis, all with lower per capita costs. Devotees of the PCMH are surging ahead to tie together the twin strands of incentives for transitioning to electronic medical records and improving on the delivery and payment models of primary care.
They have support from their major societies, all of which have wholeheartedly signed on to the PCMH model: The American Association of Family Physicians, the American College of Physicians, the American Association of Pediatrics and the American Osteopathic Association. These four groups total 330,000 members, more than a third of the practicing doctors in the United States. Even the venerable American Medical Association has joined the chorus, lending its endorsement to the concept.
[The idea of a PCMH has actually been around for decades. You can see a timeline of its evolution on page S4 here.] Early data from some of the demonstration projects show promising results, reinforcing the idea that paying for quality in health care doesn't necessarily mean delivering more care.
Yet while the PCMH sounds good conceptually, individual doctors and patients are finding it less lofty than its rhetoric. For one thing, the model presupposes the doctor as the center of a "care team," consisting of nurses and "mid-levels" (i.e. nurse practitioners and physician assistants). Under the PCMH model, doctors would only see the "complex" patients, leaving the "simpler" issues (like sore throats, colds, sprains, and urinary tract infections) to the rest of the team.
In theory, the doctor (really the doctor's team) has the ability to handle many more patients, improving both practice revenue and efficiency (attributable to the new informatics tools and data pooling). The obvious problem with this is that the patient has to buy in to the model. Some folks are fine seeing the nurse practitioner for their acute complaint, but how does the medical home model improve the doctor-patient relationship, especially if you already have trouble seeing your actual doctor?
Worse yet, with all of this restructuring, the PCMH has yet to be shown to be cost effective. Reorganization costs money, as do the startup costs of the electronic tools. Integrated systems like Group Health in Seattle and Geisinger in Pennsylvania have shown cost savings when doctors are salaried, networked, and have a captive audience of insureds to analyze. Unfortunately, the vast majority of practicing doctors still operate outside of these networks. Encouraging them to transition their practices into "homes" will be disruptive to say the least; the real question is whether the disruption will be transformative toward the ideal or cause the destruction of individualized doctor-patient relationships.
Feel free to chime in with your thoughts.
John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Labels: electronic medical records, GlassHospital, health care delivery, health care reform, medical education, patient communication, patient-centered medical home
posted by John Schumann, M.D. at
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2 Comments:
Thanks for pointing out the obvious that the PCMH presupposes use of so-called "physician extenders" and incorporates them as part of the PCMH "team". I am in an academic (salaried) medical center group practice that otherwise functions as a large private practice -- except we (by individual funding mandate) cannot use NP's or PA's even for our uncomplicated sick visits. Yet we are going head-first into the PCMH pilot group...
It's been my experience that even when my patients see very talented and qualified NP's/PA's in other departments, they almost never feel as they've been seen by "The Doctor". And even when they have seen one of my physician partners for an interim/acute visit they're never completely satisfied unless they've seen their own doctor -- even if they've received excellent care objectively. We've seen this time and time again in regards to our hospitalist system, and only now -- 5+ years into its implementation -- are patients starting to accept that it is here to stay (they still don't like it, though, on the whole).
You are absolutely right that the PCMH model will fail unless patients buy into this euphemistic "team" concept. For this to occur, practices will have to be direct and blunt about what this means from the patient point of view. Not historically our strong suit in Medicine.
Patients are smarter and savvier than we give them credit for. They are already watching out for mis-steps of a health care system of which they are growing increasingly suspicious.
Name Withheld, MD
I was asked on a hospital form who my primary care physician was, that's when it struck me...
I've never once had a face-to-face conversation with that person! I think I had seen that doctor walking down the little hallway, oh, maybe once.
On the hospital form I spelled the name wrong. And I was there to proceed with endocrine surgery to remove a tumor.
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