Op-ed: Ways to make primary care the key to health reform

The following op-ed, co-written with Rahul Parikh, was published on December 16th, 2009 in CNN.com.

America is closer to meaningful health care reform than at any time in its history. As we have all witnessed, finding a way to both provide every American access to affordable health care while seeking to control health care costs has not been easy.

Many of the proposed solutions have led to sharp disagreements, with contention surrounding what role government should play.

One goal all sides can agree on, but have yet to meaningfully address, is the need to end the crisis of primary care in the United States.

Without taking steps to fix it, any attempt at reforming our health system cannot succeed.

Consider that the number of patients without a primary care doctor is estimated to be 60 million, according to the National Association of Community Health Centers. Most patients want their medical care to be consolidated at a single office, provided by clinicians who know them well. In a survey from the Journal of the American Medical Association, 94 percent of patients preferred seeing a primary care doctor first for their medical issues.

But in most cases, patients wait weeks or months for a primary care appointment, which often leads them to the emergency department for care that ordinarily can be handled in a doctor’s office.

While nearly all primary care doctors in the United Kingdom, New Zealand, and the Netherlands offer office visits after hours, only 29 percent of physician offices in the United States offer comparable care, forcing more patients to go to the ER.

Many solutions propose to rectify the economic factors, such as lower salaries, that discourage medical students from pursuing careers in primary care medicine. But there is scant discussion of rebuilding our health care system around the primary care doctor-patient relationship. To achieve this, three ideas are essential: teamwork, technology and integration.

Creating effective teams can help doctors focus on patients’ well-being. At the Medical Associates Clinic and Health Plans in Dubuque, Iowa, for instance, support staff at all levels work closely with doctors and patients to ensure a productive encounter.

Nurses huddle with their doctors prior to each visit and summaries of patients’ lab tests, notes, current medicines and problems are reviewed. Receptionists are also involved, scheduling lab tests before and after encounters to ensure that doctors and patients have the information they need at each visit to change the plan of care.

General practices in the United Kingdom use a similar team-based approach, and studies show that such teamwork is associated with improved care for patients with diabetes along with better continuity of care, access to care, and patient satisfaction. By contrast, according to a recent Commonwealth Fund survey, “U.S. physicians have not led in implementing … the use of teams.”

Technology already plays a prominent role in medicine. But much of it, like imaging scanners and robotic surgery, is used by specialists to diagnose and treat illness. In contrast, primary care doctors rely on these high-tech tools sparingly. Yet technology can strengthen the relationship between physicians and patients by improving access and convenience for both.

One example is simple e-mail, which is beginning to make inroads in health care. A study from the University of Pittsburgh School of Medicine showed that parents who used e-mail to communicate with their child’s physician increased access and improved the quality of care.

Parents did not report that e-mail distanced them from their child’s doctor and physicians found that answering patient e-mails was 57 percent faster than using the phone.

Finally, if we build a health care system around the primary care doctor’s office, then all other facets of care must be integrated with it. Specifically, involving specialists in the primary care experience can provide comprehensive care efficiently.

At Kaiser Permanente in Northern California, specialists have introduced “p-consult” to provide this kind of integration. When a patient comes to see their primary care doctor with a problem that requires specialist input, the primary care doctor can call the specialist immediately from the exam room for consultation.

Both primary care doctors and patients report that the program helps them get care right the first time, avoiding redundant visits and tests that drive up costs. For specialists, “p-consult” helps keep their access open for patients who need to be seen.

According to the World Health Organization, health care systems centered around primary care have lower costs and better outcomes, which Congress has recognized by acknowledging the need for reducing the gap between what primary care doctors and specialists are paid. However, ideas to make it easier to deliver primary care and strengthen the doctor-patient relationship need to be at the forefront of the health reform conversation.

Improving primary care in America needs to be about more than the money.

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  • Philip

    I have practiced primary care for 30 years, largely in academic settings. I value all the good things about it…continuity, knowledge of patients, etc. BUT, make no mistakes, after hours requirements, On CALL (frequently for the most trivial of concerns), extended office hours, all take their toll and prompt many MDs to declare the practice unacceptable despite its rewards. These onerous tasks are peripheral to the rewards of primary care practice and should be staffed and compensated by individuals motivated to perform these duties. If included in the package called “primary care” I guarantee all that the “specialty” will wither and die.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Academic setting are nice. At least they have some “netting”.

    I’m a Pediatrician who has practiced as a Locums/Independent-Contractor in rural areas for almost twelve years (since being professionally raped, robbed & left for dead by my hometown “non-profit” for the sin of saving a baby’s life/blowing-the-whistle . . . while in public service no less . . . but that’s a whole nuther primary-care nightmare). And these places are all the same.

    A small, middle-of-fricking-nowhere hospital in desperate need gets it’s hooks into you under certain conditions (some spelled out in contract/some understood on good faith). For a while they are grateful to have you and treat you very well. But when the conditions change (i.e. other doctors leave/budgets gets tight/duties escalate – often exponentially), the hospital starts dumping more and more on the physician while wanting the physician to adhere strictly to the terms of the contract – with no additional consideration or compensation. They want someone there to clean up their messes, but they don’t want to pay them.

    And these “suits” do not begin to understand what “on-call” means in these settings. Meanwhile, patients are entitled to everything – as if medicine is Walmart.

    I’m sorry folks. Doctors, who spend huge chunks of their lives training to be what they are – and go into massive debt – can’t work for nothing. And they shouldn’t. Moreover, they don’t. Some places become revolving doors. And they DESERVE to be.

    As a physician with many years experience, I’ve been housed in nasty/seedy motels those executives wouldn’t set foot in (on the cheap) – one Federal clinic even tried to put me in a “dorm” with male medical students. You’re in these situations, literally saving somebody’s butt, but you’re treated like dirt. Needless to say, I don’t put up with stuff like that, and if it’s not fixed, I move on.

    There are HUGE problems in primary care that neither of Obama’s precious House/Senate “reform” bills now being secretly reconciled get remotely near: Tort reform. Peer Review reform. Whistle-blower protection. “Non-profit” oversight. Real administrative accountabilty (as opposed to lip service). Most of those problems have NOTHING to do with doctors and nurses (or the care they provide) and EVERYTHING to do with businesspeople and lawyers who have devalued the primary care physician and taken them for granted to the point that I’m not sure the profession can survive.

    Someone has to wake up. Soon.

  • Tom

    I take issue with your saying that the healthcare reform will not succeed. What it is aimed at is bringing all of healthcare under government oversight, with an eventual goal of controlling payment. In that respect, I suspect the “healthcare reform” will succeed very well.

    While I sympathize, what you propose above is not going to happen. The world of healthcare is not going to re-align around the PCPs, no matter what plans you draw up. There is no turning the clock back; we must plan for the world we live in, rather than the world we wish we lived in.

    What should concern you is how to preserve the role of PCPs. There are few patients who question the value of PCPs, the issue is that no-one in insurance or government is interested in paying them. Pay remains a proxy for how much those organizations value them. Your proposals do not address this. Nor do they address the other causes of dissatisfaction among PCPs.

  • ray

    I totally support the team model with easy access including after hours and weekend. It would dramatically cut down ER load and by that itself we weed out wasteful costs. More important, Primary care should tune itself to start treating and getting comfortable taking care of some specialist issues, if there is no effort to implement, all these systems will fail miserably because all PCP does is REFER, REFER…. there needs to be emphasis on clinical things that Primary care can handle and can learn to handle. Right there is no incentive to handle it. Kaiser probably works at this, most systems don’t care enough and care is so fragmented. If we support primary care, we can get many things right including referring appropriately to specialists.

  • Classof65

    I think that ray has the right idea — the team approach can work to cover the so-called “off hours” and would provide for real days off and vacations! Providing an evening “surgery” (as in Britain) could also prove to be useful in reducing emergency room visits, less costly to patients and available to those who are at work or school all day…. One of the doctors in our little town has taken on additional nurse practitioners and a new doctor partner and has expanded the hours that medical care is available to local patients and it seems to not only work, but to be quite profitable.

  • http://wellescent.com/blog/siteblog.php?entry=seeing-the-invisible-in-fibromyalgia Wellescent Health Blog

    Given the complexities that can be associated with maintaining our overall health, a team approach with appropriate expertise makes significant sense. Add to the that the ability to avoid all the back and forth communication simply to hand patients from one doctor to another and the efficiencies associated with such an approach become further evident. Furthermore, enabling doctors to focus their efforts on patient diagnosis and treatment while handing off other responsibilities to other members of the team reduces stress on the doctor.

    If more functional team operations were put in place and doctors had to spend less of their time in the dual role of sole proprietor and physician, then both patients and doctor would surely benefit.

  • jsmith

    Behind Curtain Number One. Primary care: be on call, take care of everything, manage the team, save society boatloads of money. That’s what you can do for us, doctor. What can we do for you? Well, we can underpay you, give you work and responsibility without limit (including in the middle of the night!!), destroy your family life, and generally treat you like the chumps that you most demonstrably are.
    Behind Curtain Number 2: Subspecialty. Much more money, enough in fact that you can run your own practice at a profit without kowtowing to business types, more respect, no responsibility to manage the total patient and thereby get hit with administrivia from every point on the compass, and oh, did I mention much much much more money?
    Which would you choose?

  • http://www.bench-press-blueprint.com Bill Davis

    It’s about time that healthcare reform occurs! However, in its present state, the health bill doesn’t do enough. Our members of Congress always do as little as possible for its constituents and as much as possible for big business. It’s where the money is.

    Forced health insurance only serves to enrich the companies that are to blame for the current mess.

  • CSmith

    A simple proposal. Tax health insurance premiums 10-12%(payable by insurer). This should amount to about $700/person on average including the uninsured($2.1 trillion/300 million). Patients receive vouchers with differing values depending on comorbidities. They use these vouchers to purchase primary care. Providers who currently might have revenue of $500,000/yr for a 2000 patient panel($250/pt) would compete for these patients who provide almost 3X their current revenue/pt. In return, doctors would have to offer more office hours (80-100/wk through cross-covering, extenders,etc), provide chronic disease management(specialty nurses, educators, interactive technology) and adhere to certain standards of efficient care ( think protocols for LBP management from an independent source like UPTODATE). Primary care would be compensated on par with specialists and could recruit new practitioners from residency. ER visits could be curtailed and everyone including the 40-50 million uninsured would at least have a PCP. Insurance companies would not have to pay anything else for primary care and would likely save money through decreased ER utilization, decreased hospitalizations and adherence to efficient, competent medical standards.

    Of course everyone would have access to the national primary care EMR which specialists, hospitals and labs would interface further enhancing coordination of care. No more worrying about how to make all of the different EMRs communicate.