How else can we improve our primary care system?


Part of a series.

I have advocated in this series of posts on direct primary care in one form or another (i.e., membership, retainer-based, concierge and various other incarnations and conceptions) because it works well for both patients and primary care practitioners. Direct primary care allows the doctor the opportunity to give the type of outstanding care that each of us needs, whether currently healthy or beset with multiple chronic illnesses.

But there are many other innovative transformations can be successful. Here are a few other approaches that also create a reasonable PCP-to-patient ratio and, therefore, the time each patient needs and deserves:

  • Capitation, in which the PCP receives a large enough per-member per-month fee that the total number of patients drops from the current number. As just one example, I posted about a Medicare Advantage plan offered through a group of continuing care retirement communities.
  • Insurers change the fee-for-service reimbursement methodology to assure better care of chronic illnesses and enhanced preventive care, as described with a commercial insurer.
  • Insurers decide to pay a monthly fee for direct primary care, as did the Nevada Health Co-op in association with Turntable Health, in which the usual requirements of insurers were waived in lieu of a fixed monthly payment (The NHE was, for other reasons, ultimately not successful financially.)
  • Insurers, employers, unions or associations contract with organizations like Iora Health to provide primary care unencumbered by the usual insurance mandates, with only a reasonable number of patients per doctor depending on circumstances and with an emphasis on a team approach and health coaching.
  • Insurers agree to a contract with a provider organization that places extensive resources into primary care for the benefit of those with multiple chronic illnesses and socioeconomic deprivation, as with a Medicaid contract with a provider company to care for the “sickest of the sick.”
schimpff chart

In each of these examples, the intention — whether stated or not — was to convert from a dysfunctional medical care delivery system to a true health care delivery system. When this happens, it is clear that the quality of care rose, and the total costs declined, often dramatically. In each the key was innovation — stepping away from the current system and constructing a new, better approach.

In each, as with direct primary care, the goal was to create a primary care delivery system that offers high-quality care to a satisfied patient by an enthusiastic and energized physician (or other provider) at a reasonable cost that lowers the total cost of care. All who have the needed abilities and expertise can develop their own solutions to the problem. These individuals are at the front line, so they know better what will work in their settings. The solutions can be sorted out in the health care marketplace, with the best of each ultimately used together.

What has always driven individuals to become physicians is the opportunity for a trusting, meaningful and useful relationship with the patient. This relationship is the heart of primary care. The goal today should be to enhance that relationship by assuring that the PCP has the needed time with the patient for listening, thinking, preventing, treating and coordinating. That means fewer patients per doctor and it means much less nonclinical busy work dictated by others. Another part of the goal is to reduce the burden on the PCP by making better use of the team.

A third element is to assure a proactive approach with all patients at all times, not just when they show up at the office with a problem. When the PCP-patient relationship is present, the workload of the PCP is reduced, and the entire patient panel is proactively managed by the primary care provider and team, then the PCP becomes the backbone of the U.S. health care delivery system. This means assurance of excellent care, increased satisfaction for both provider and patient and reduced total costs of care. It means a health care system, not the dysfunctional medical care system of today.

Crisis-2 jpegStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO, University of Maryland Medical Center, and senior advisor, Sage Growth Partners.  He is the author of Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.

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