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The Crisis in Primary Care

Posted May 14 2010 5:06am
From today's NY Times
Delivering Better Primary Care
By PAULINE W. CHEN, M.D.

What is clear is this: primary care is hurtling toward a crisis point. Once lauded as health care’s frontline clinicians, primary care practitioners — general internists, family physicians, geriatricians, general pediatricians, nurse practitioners and physician assistants — are instead struggling with growing paperwork demands, inadequate and misaligned reimbursement and dwindling numbers of providers.

Now, with 40 million more patients on the horizon, the discussions about the fate of primary care have taken on an even more frantic tone, reminiscent of a common clinical scene. When it comes to the sickest patient in the hospital, everyone else always has an opinion about the best thing to do.

What is not so clear though in the primary care debate is which of these many opinions we should heed. Should the perspective of presidential advisers, policy wonks, research whizzes or political pundits shape the future of care delivery? Or should we listen to the community practitioners who provide the overwhelming bulk of primary care in this country, practitioners like Dr. Richard J. Baron?

Over the last month, Dr. Baron, a general internist and geriatrician who leads the Greenhouse Internists, a five-physician primary care practice in urban Philadelphia, has published two papers, both of which address the present and the future of primary care from the perspective of a community physician. The first paper, which appeared in The New England Journal of Medicine and bore the provocative title “What’s Keeping Us So Busy in Primary Care?” documents in stunning detail the “invisible” work that primary care practitioners must do in addition to seeing patients each day. There are on average 17 e-mail messages to write, 14 consultation reports to review, 24 phone calls to field, 11 X-ray and imaging reports to read, 12 prescriptions to refill (not including those done during a visit or phone call) and 20 laboratory reports to be checked, all on top of the work involved in seeing a daily quota of at least 18 patients.

Dr. Baron’s more recent paper in the health care policy journal Health Affairs describes how his practice has attempted to move away from the traditional fee-for-service care model to a more comprehensive one that is centered on the patient and preventive care. As part of a three-year statewide and multipayer-financed initiative that compensates providers for not only office visits but also prevention and disease management, Dr. Baron’s group has developed a program that encourages continuing dialogue between providers and patients with diabetes, high blood pressure and elevated cholesterol, patients who make up nearly three-quarters of the group’s practice. Patients meet with trained medical assistants and create a set of self-management goals that become part of their electronic medical record, then share the results of their efforts with the medical team on an interactive Web site and during follow-up calls.

But, as Dr. Baron notes, even with the best of intentions and the financial support of several insurance companies and the state, changing the way primary care is practiced has been both difficult and costly for the care providers in his group. As he writes
“Transforming primary care — from easily measured, time-limited activities that closely track the existing reimbursement system to more valuable but also more time-consuming ones, such as supporting patients as they become engaged in managing their own health — is a complex process.... Although many physicians welcome such a challenge, it is also an expensive diversion from revenue-generating activities that adds to the pressures on an already strained primary care business model.”

I spoke to Dr. Baron recently and asked him about the inspiration for his practice’s innovative program, his strategies to revitalize primary care and lessons he has garnered from the experience.

Q. What inspired you to incorporate this collaborative chronic disease care program into your practice?

A. As part of the pilot program for patient-centered medical homes, we were given additional funds to create a collaborative care model. The funding gave us some leeway to start this project and allowed us to really engage in the issue of improving chronic illness care as a set of practicing doctors. We got to spend time thinking about the changes we could make to improve chronic care. And we ended up not using anything that wasn’t already widely known. There’s a lot of research about behavior change and getting people to change their behaviors.

What most of us in primary care want is for our patients not to have complications that can be prevented. But we are going to need support, help, a technological understanding at the point of care. It cannot be that everyone else in the world has robots sending us e-mails reminding us that this or that hasn’t happened, and the poor primary care practitioners are scrambling around to catch up without the benefit of similar capabilities or equipment.

Q. The subtext of your articles seems to indicate that we need a paradigm shift in the way we think about care, or at least reimburse it.

A. When you think about what a year’s worth of statins, or cholesterol-lowering drugs, cost in terms of pricing, monitoring the effects and follow-up, there are a lot of resources being used right there. But if you take those resources and put them into a program like this that achieves meaningful levels of behavior change, a lot more patients could be better off. We are really struggling to find models of care like this one because there’s not much money being allocated to research like this. There is, on the other hand, generous funding for the next iteration of the latest statin drug, a drug that only needs to be 10 percent better to make it to the market. But programs like the one we are trying to build could have an effect in the 30 to 40 percent range and maybe with a lot less money involved.

I think that over the last decade or two in primary care we’ve had what I would call an unproductive conversation. We primary care practitioners have been saying that we either already do or would do certain things if you paid us more. It’s true that you can’t do things consistently, reliably and across scales without additional payment. But payment is not enough. People have to change what they are thinking about when they go to work.

And even as primary care doctors have complained about the unfairness and inappropriateness of the payment system, we have wound up designing, and to some extent have had to design, our practices around it. This has created an ecosystem where certain kinds of behaviors flourish and some, like the collaborative care model we are trying to use, don’t.

Just making it rain more, throwing more money around, won’t make those things flourish.

Q. How can we help more patient-centered and collaborative models flourish?

A. We are in a kind of Gordian knot right now. We have models for creating new devices or drugs: pharmaceutical or biotech companies create partnerships with academia. Someone says we are going to create a laboratory, shelter you, then figure out how to bring your product to the market. When devices or drugs get developed in this way, it is not under market conditions.

But we have not had the same situation in primary care. We haven’t had a protected laboratory for people to innovate around service delivery and to try to figure out how we can do better. There are huge opportunities to do our work more effectively and consistently, but we haven’t had the same kind of support.

In fact, I’m not sure we will be able to continue the new program in our practice if we cannot get resources to support us beyond the three-year commitment.

Q. What are the lessons from your experience?

A. I think that we primary care practitioners need to think about redesigning our practices not so much around the payment system but around what we think are the opportunities to add value to our patients. It’s going to be a different kind of primary care in the future. If we free ourselves to ask what we can do to make a difference for patients, I think we will find ourselves full of ideas.

The policy people on the other hand have to figure out how to encourage people to unlock themselves and give better value in primary care. They cannot expect that to happen in a system that so punishes people who are trying to do this.

People do not make the best doctors or policy people or advocates from a position of anger. We have to think more about what we all want and how we can move toward that.
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