The Radical Rethinking of Primary Care Starts Now

by Dan Diamond, California Healthline Contributing Editor

TOPIC ALERT:

In November 2008, the New England Journal of Medicine convened a small roundtable to discuss "Redesigning Primary Care."

U.S. primary care is in crisis, the roundtable's description reads. As a result ... [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.

Nearly five years out -- and dozens of reforms and pilots later -- the primary care system's condition may still be acute. But policymakers, health care leaders and other innovators are more determined than ever: After decades where primary care's problems were largely ignored, they're not letting this crisis go to waste.

Ongoing Shortage Forcing Decisions

The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.

It's a predicament that leads to shared suffering for patients (who face long wait times), primary care physicians (who are exiting the business), and the nation's health system (which bears the burden of added, expensive interventions by specialists).

The Affordable Care Act does include a number of provisions intended to strengthen primary care; for example, the law increases payment rates for PCPs in 2013 and 2014, launches new training programs and includes a slew of pilots.

Altogether, experts expect that the law will increase the number of PCPs by about 3,000 over a decade -- but that would still leave the nation more than 40,000 short by 2020, according to estimates from the Association of American Medical Colleges.

That's partly because of the ACA's own coverage expansion. The nation will need as many as 7,000 more PCPs to care for the millions of newly insured patients under the law, one study concluded.

"Both the challenge and truth is that as a practical matter," writes Peter Long, president and CEO of the Blue Shield of California Foundation, "it is not possible to fill the provider gap by 2014."

Ongoing Debate Over Clinicians' Roles

One approach to the provider shortage is to redefine which providers can actually deliver frontline care.

"We need to think more clearly about whether it is more primary care physicians that we need," Dr. Peter Ubel writes at Forbes, "or instead, more primary care clinicians: nurse practitioners, physician assistants, and the like."

And it's clear that some non-physician providers are seizing on the ACA in efforts to advance their roles. As the Washington Post's Sarah Kliff writes, nurse practitioners are again pushing to expand their scope of practice and take on more primary-care duties. In Oregon, chiropractors are moving to be considered as primary care providers. 

Broader Push for Innovative Redesign

But increasing manpower alone isn't enough. (And it's also possible that experts inflate current predictions of a PCP shortage, researchers at Columbia University and the University of Pennsylvania's Wharton School recently concluded. Traditional models, such as calculating doctor-to-population ratios, underestimate modern medicine's ability to provide care to more patients with fewer doctors.)

That's why many other attempts to more radically transform primary care are under way, ranging from changes in how care is delivered to where patients are being seen.

Providers latch onto the patient-centered medical home model: More than 45 years after its debut, the medical home concept -- where a team of providers collaborate to deliver primary care -- is finally taking hold.

Hundreds of hospitals, medical groups and community clinics are piloting PCMHs, with a boost from payers and lawmakers. A 2012 study from the Commonwealth Fund found that about half the states have implemented PCMHs for their Medicaid populations.

Paramedics stop waiting for emergencies: Hospitals in several states are piloting a model where paramedics pay proactive house calls to frail and elderly patients, in order to perform basic tests and unusual interventions -- everything from helping arrange for a wheelchair ramp to even baking cookies.

The new model ("We are kind of inventing this," according to one community paramedic) is intended to keep patients out of the ED.

Pharmacy chains push into frontline services: As covered in a recent "Road to Reform," Walgreen has redesigned many stores to bring pharmacists out from behind the counter to instead sit at open desks and offer medication consults. Like its competitor CVS, the chain also operates hundreds of in-store health clinics targeting patients with low-acuity problems.

Meanwhile, Rite-Aid announced last week that it's expanding an in-store consult service, where customers can pay $45 to have a 10-minute video chat with a physician.

Insurers moving into care delivery: After mostly withdrawing from integrated delivery systems in the 1990s, payers have purchased a number of clinics and medical practices in recent years, as they experiment with tactics to hold down care costs and better integrate wellness.

In one of the most striking deals, United Health last month announced that it was partnering with The Villages in Florida -- perhaps the nation's largest retirement community, with nearly 100,000 residents -- to launch a network of primary care clinics dotted throughout the three-county community.

"When our system is finished, [health] care will be just a golf-car-ride away for all Villagers," predicts The Villages CEO Gary Morse.

Private sector attempts to redesign primary care 'from the ground up': One Boston-based startup, Iora Health, has opened a handful of practices designed to deliver more hands-on primary care, with each patient being paired with a health coach who stays in touch between visits.

The model cuts out health insurers -- employers pay a flat monthly fee for each employee who joins an Iora practice -- in hopes of trimming administrative costs and encouraging patients to be more personally invested in their care.

"What everyone else is trying to do is improve existing practices, making incremental improvements," Iora founder Rushika Fernandopulle told the Boston Business Journal last year. "We figured out that maybe what we need to do is start from scratch."

Looking Forward

For decades, primary care took a backseat to specialty care innovations.

No longer.

A "redesign of primary care services and structures" explicitly underpins the "Triple Aim" of Don Berwick's Institute for Healthcare Improvement, a concept that Berwick brought with him to CMS. Nearly every major heath conference these days includes a session on primary care transformation.

Harvard University even launched a first-of-its kind center for primary care, designed to help educate future physicians and be a hub for research.

The focus on rethinking primary care is a huge opportunity -- one that's drawn non-traditional players like pharmacies and insurers, but big-box stores like Wal-Mart, too.

"This new vision for primary care requires several fundamental power shifts," Iora Health's Fernandopulle wrote in Health Affairs last summer, touting his model.

And "no one likes giving [power] up voluntarily ... [but] it is ultimately in the medical industry's interest to adapt and innovate with consumer trends, or risk becoming obsolete, as many travel agents, book stores, and stock brokers have learned over the past several years," he concludes.

Weekly Roundup

Here's some of the other key health reform news and commentary from around the nation.

Florida: A panel of House Republicans on Monday voted to override Gov. Rick Scott's planned Medicaid expansion. While the vote doesn't mean the expansion is dead, it does represent a blow to the governor's plan.

Arkansas: Writing at Project Millennial, Adrianna McIntyre and Karan Chhabra review the legality of Gov. Mike Beebe's innovative deal with HHS to expand health coverage in the state. Meanwhile, the state's hospital association on Monday released a study -- conducted before Beebe's deal -- concluding that opting into the Medicaid expansion would save the state $664 million across the next several years.

Massachusetts: A new study finds that the state's expansion of health coverage in 2006 didn't have a negative effect on previously insured patients, Harvard's Ashish Jha writes at "An Ounce of Evidence."

hilda may
Addressing the spokesman from DHCS please check your data we do not have access to the amount of primary care doctors. We must be careful in letting non Medical doctors treating patients education in medicine is there for a reason. Walgreen's Pharmancist I know some that could be educated to treat patients within level one medical issues. Chiropractor is a great resource. Making changes and preparing for 2014 is the educated thing to do.
Hrant Kouyoumdjian
Good apolitical overview. Read with the 3/4/13 article on Medi-Cal expansion impacting provider shortages, who defines the parameters of the discussion determines the prescribed policy options and outcomes. It is an empirical fact that both access and accessibility (the latter is the ease by which one receives care once gained access into the system) have been and continue to remain barriers for many Medi-Cal beneficiaries. Definitely the reimbursement levels to providers (institutional and non-institutional) is a major concern, among other variables. The ACA provides temporary pay incentives to PCs but it's not a panacea to real shortages. Which brings us to the begging question of who defined and empirically measured/benchmarked what "adequate" is in this statement from DHCS spokesperson: "We do believe that the Medi-Cal provider network provides adequate access in California now." Those are the type of questions that need further policy inquiry and investigative journalism.

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