Nov 4 2013
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Stimulating Primary Care Transformation

Michael Hochman, MD, MPH, is medical director for Innovation at AltaMed Health Services, a 43-site federally qualified health center in Southern California.  He completed the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at the University of California, Los Angeles, and the U.S. Department of Veterans Affairs in 2012.  While a Clinical Scholar, Hochman co-led a primary care demonstration that was published last month in JAMA Internal Medicine.  He recently published, 50 Studies Every Doctor Should Know.

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Primary care in the United States is at a crossroads.  As health care becomes increasingly disjointed and costs continue to rise, primary care providers face increasing pressure to take charge of the health system.  Indeed, we know that health care systems with more developed primary care infrastructures are more efficient and of higher quality than those with a weaker primary care foundation.

But at the same time, more and more health care professionals are shying away from careers in primary care.  Not only is the work challenging (late-night phone calls, numerous tests and studies to follow up on, ever-increasing regulatory requirements), but the pay is lower than in other fields of medicine.

To help reinvigorate primary care, several leading primary care societies recently issued the joint principles of the patient-centered medical home (PCMH).  The PCMH principles underscore the hard work that is necessary to provide high quality primary care services, such as coordinating care with specialists and hospitals, providing telephone access for patients and after-hours appointment time slots, outreach to promote appropriate preventive care, and quality and safety efforts, to name just a few.  The PCMH model also calls for enhanced payments from third-party payers to cover the cost of providing these intangible services.

Thus far, the PCMH initiative has succeeded in stimulating numerous health systems to embark upon primary care transformation efforts guided by the PCMH principles.  The Affordable Care Act (ACA) also calls for a multi-state PCMH demonstration.  Most of these demonstrations—including one I recently helped to co-lead[1]—have led to important improvements.

But unfortunately, few third-party payers have thus far adjusted reimbursement to cover the cost of primary care transformation.  As a result, the impact of PCMH initiatives on our primary care system has not been as profound as it needs to be[2].  In the few instances where there has been adequate and sustained support for PCMH transformation (the Group Health Cooperative in Seattle[3], the Southcentral Foundation in Alaska[4], and a PCMH demonstration supported by a dominant third-party payer in Michigan[5]), the impact of PCMH-guided interventions has been much more pronounced.

Where does this leave us?  We have something of a chicken-and-the-egg problem.  Primary care systems are being called upon to transform and take on our most pressing health care challenges, but many don’t have the resources (either financial or staffing) to do so effectively.  Third-party payers, on the other hand, don’t want to invest in primary care systems that may not be successful in their transformation efforts (or which will require considerable time to succeed).

Still, I am hopeful.  Key recent initiatives, including several legislated in the ACA, demand greater accountability from health care providers for improving patient outcomes in a cost-effective way.  As health care providers, we know that primary care is a key ingredient to doing this.  As incentives increasingly align with high value care, I believe this will provide the much needed stimulus for health systems to invest in primary care.  These investments should reap dividends for patients and, ultimately, will make our health system more efficient.

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[1] Hochman ME, Asch S, Jibilian A et al.  Patient-Centered Medical Home Intervention at an Internal Medicine Resident Safety-Net Clinic.  JAMA Intern Med. 2013 Sep 4. [Return to text.]

[2] Margolius D.  Less Tinkering, More Transforming: How to Build Successful Patient-Centered Medical Homes.  JAMA Intern Med. 2013 Sep 4. [Return to text.]

[3] Reid RJ, Coleman K, Johnson EA et al.  The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers.  Health Aff (Millwood). 2010 May;29(5):835-43. [Return to text.]

[4] Driscoll DL, Hiratsuka V, Johnston JM, et al.  Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation. Ann FamMed. 2013;11(11)(suppl 1):S41-S49. [Return to text.]

[5] Paustian ML, Alexander JA, El Reda DK et al.  Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs.  Health Serv Res. 2013 Jul 5. [Return to text.]  

Tags: Clinical Scholars, Health Care Workforce, Research & Analysis, Voices from the Field