What does a new model of primary care look like?

Part of a series.

Here is a model for the delivery of primary care which offers certain rights balanced by responsibilities for patient, provider and insurer alike.

First the rights of each party. As a patient, you deserve a high level of care in a satisfying manner without frustrations. The insurer and your employer want to see the total cost of health care come down. The physician wants the satisfaction of offering outstanding care, a reasonable income, and a reasonable home life.

If those are the “rights” then here are the “responsibilities” in a well-functioning system. The PCP has the responsibility of providing thorough care of patients. Thorough care includes being available on reasonable notice, with timing dependent on acuity. The patient visit should be long enough to fully assess and treat the problems, including underlying emotional anxiety and stress. The doctor must allocate sufficient time to listen and think. If there is a need for a specialist, the PCP should personally call and explain the reason for the referral and seek a prompt appointment. After the specialist visit, the PCP may need to reinforce and interpret the specialist’s recommendations for the patient. When the patient’s illness requires multiple specialists, the PCP needs to accept the role of coordinator of care (probably with assistance from an office team member) to ensure that each specialist is cognizant of the other’s recommendations and that tests and prescriptions are neither duplicative nor will they lead to adverse interactions.

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The PCP should also offer, perhaps via other team members such as a health coach comprehensive preventive care, including advice about wellness and health, appropriate screening for treatable conditions and management of immunizations.

Health promotion and disease prevention must not be left to the current approach of waiting for the patient to choose to visit the office. The doctor and his or her team should actively reach out to all of the patients in the practice. The team must determine who is at risk and then offer logical and intensive approaches for prevention and wellness maintenance. No longer can the health care team wait for the patient to call. Instead, they must create an in-house mechanism to stay in contact with the patients.

As a patient, you should be able to communicate as appropriate — by email, Skype or other digital means — and you should be able to call the PCP directly via cell phone during off hours if necessary.

The insurer is responsible for paying the PCP an appropriate amount for the services rendered and must do so without undue administrative requirements.

The insurer (and whoever pays the insurer such as employer, government or you) benefits with reduced total costs of care. You benefit with improved care and a meaningful relationship with your doctor. You will also benefit over time with reduced or stable health insurance premiums.

This sounds like a tall order, but it is quite possible. They key is a payment model that is designed to ensure the PCP has the right number of patients and time to accomplish all of the above, including funds to do the health coaching, practicing proactively rather than reactively, etc. At the same time, the payment model should force the physician to be accountable for the total health of each patient: population health. This means reorganizing the office team along the lines of the patient-centered medical home, although free of the burdens of unnecessary bureaucratic forms and checkboxes as is presently the case. It means assigning responsibility for data collection and entry, proactive population health approaches, preventive medicine, and chronic illness care coordination to the other clinicians on the team. By doing this, the PCP frees up time for complex issues and critical patient-PCP personal interaction, time to listen and time to think.

If this can be achieved with new models of reimbursement and a return to the old model of intense relationships with patients, then primary care will survive to drive the rest of the health care system to excellence at a much lower cost.

As a patient, the choice is yours. You have every right to quality care, but there is “no free lunch.” The “right” to health care should not be interpreted to mean free health care. In the end, you must match your personal expenditures with your perception of your, and your family’s health care needs to choose what is best for your circumstances.

I am well aware that most Americans are not yet informed about the issues in primary care. Most do not realize how important and valuable true primary care can be to their health overall. Most people see primary care as for the “simple” problems and expect to see the PCP only episodically. A new paradigm is often difficult to embrace, but it is especially difficult when its purpose and logic are not appreciated. Americans have become used to an insurance model that purports to be prepaid medical care, and most of us are skeptical of stepping away from what we know. We are also not yet fully cognizant of the value of good preventive care. In addition, most are not familiar with the concept of population health or a proactive approach to managing health and wellness instead of only illness. All of these will need to sink into the collective consciousness before real change can occur.

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.

Image credit: Shutterstock.com

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