Explaining the critical gap of primary care physicians

There is a critical gap in the supply of primary care physicians in the U.S., and it should come as no surprise that our existing primary care delivery and payment models are at the heart of the issue.

The traditional primary care model — medical care provided by a physician and a small support staff, often without benefit of health information technology (HIT) — was developed at a time when the physician was focused on responding to “sick” patients with acute symptoms of illness.

Today, primary care providers are expected to focus on keeping patients “well.” This entails doing much more for each patient during a typical office visit — recommending and discussing a variety of age-appropriate preventive services, for instance, or monitoring and coordinating multiple chronic conditions for a growing number of aging patients.

Most of the existing primary care payment models are aligned with the traditional model, with fee-for-service representing more than 90% of practice revenue. But with steadily increasing demands on their time for prevention, screening, education, and complex care coordination, many primary care providers are no longer able to make a living from office visits.

As the pressures of work and financial stresses worsen for primary care providers, fewer medical students are choosing careers in the field, and existing practitioners are opting for early retirement or making career shifts.

In the health policy arena, there has been much discussion centered on increasing the number of primary care physicians and creating incentives to encourage them to embrace population-based primary care.

Effective population-based care — which is concerned with health outcomes of individuals in a group — includes interventions to reach, educate, and eliminate barriers to care. A key goal is to moderate the impact of factors such as lifestyle and behavior, socioeconomic circumstances, employment status, and the environment.

Population-based primary care is proactive and team-based. Moreover, it is the model for the “medical home” envisioned by those who crafted the national health reform legislation.

The patient-centered medical home (PCMH) is essentially delivery of holistic primary care based on ongoing, stable relationships between patients and their personal physicians. It is characterized by physician-directed integrated care teams, coordinated care, improved quality through the use of disease registries and health information technology, and enhanced access to care.

Importantly, the medical home model involves additional monthly payments to primary care physicians in exchange for which they lead prevention, disease management, and care coordination activities that reflect best practices.

The primary care medical home concept has captured the attention of providers, payers, purchasers, and policymakers alike. Demonstration programs across the nation show promising early outcomes, and the model is viewed as one means of reorganizing primary care under healthcare reform.

The working hypothesis is that primary care physicians will be motivated by population-based reimbursement incentives and be more inclined to join with other primary care providers and add additional support staff and technologies, which will enable them to broaden their scope of care and services.

This year’s health reform legislation also sets forth another interesting concept — the accountable care organization (ACO) — as a strategy to address the shortcomings of the U.S. healthcare system in general.

Although ACO payment models vary, the core principles remain the same:

  • Provider-led organizations with a strong primary care base, collectively accountable for quality and total per-capita costs across the full continuum of care for a specific patient population
  • Payments linked to quality improvement that also reduces overall costs
  • Reliable and progressively more sophisticated performance measurement

Clearly, primary care is essential to the success of ACOs because the model is firmly rooted in relationships that exist between primary care providers and their patients.

Implementing the medical home concept and ACO simultaneously could address budgetary concerns while providing more incentives for care coordination.

ACOs developed and tested in combination with PCMHs would constitute a substantial shift from volume-based payment to value-based payment.

Although healthcare reform legislation has created the perfect opportunity for redesigning primary care, achieving such major change will not be easy and will require more than legislative reforms.

It will take leadership from physicians and other healthcare providers and public and private payer support. And it will take changes to reimbursement that reduce the primary care specialty income gap and support investment in necessary practice improvements — e.g., additional support staff and health information technology.

Public policy interventions must be crafted with care in order to support opportunities such as:

  • Educating primary care providers
  • Funding pilot projects
  • Creating laws tying payment to solutions that deliver the greatest quality for the least cost
  • Fostering the creation of ACOs that unite traditional medical care with innovative primary healthcare delivery, especially those that incorporate population health solutions

In his recent commentary in Health Affairs, David M. Lawrence envisioned a “scalable, technology-based, disruptively reliable, affordable, direct-to-consumer primary health ‘front end’ consisting of state-of-the-art wellness programs that help consumers incorporate risk-reduction strategies through behavior change, preclinical disease screening and referral, chronic disease monitoring and self-management, triage, and navigation support when an individual requires sick-care.”

I remain optimistic that, with thoughtful public policy, adoption of the primary care medical home concept, appropriate payment reform, and development of accountable care organizations, our redesigned system will boost the health status of Americans and improve the quality of healthcare delivered by providers — all at lower cost!

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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