Why was the Patient Centered Primary Care Medical Home unsuccessful? It was not really implemented!

 

In a recent post on the blog of the Medical Care section of the American Public Health Association (APHA), Dr. Gregory Stevens wrote Is something going wrong with the Patient-Centered Medical Home? His concern was engendered by the results of a study in the journal Medical Care (also published by the Medical Care section) by Colasurdo, Pizzimenti, et al., “The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results”. This study examined a sample of practices implementing the PCMH model and showed varied results. The trends were toward more emergency visits, fewer hospitalizations, and unchanged costs. This was not supposed to be the result, and was a disappointment to Dr. Stevens, especially given that he was mentored by Dr. Barbara Starfield, whose research documented the beneficial impact of Primary Care on quality of care, cost, and population health.

First, some effort to clarify the terms; PCMH stands for both Primary Care Medical Home (as it generally does in the settings studied by Colasurdo, et al.), as well as Patient-Centered Medical Home, which is the term Dr. Stevens uses (actually, Colasurdo. uses both. The fact that both Primary Care and Patient Centered have the same initials is kind of cool, but it can be confusing, Indeed, in 2006 an organization called the Patient-Centered Primary Care Collaborative (PCPCC) was created. The impetus came from Dr. Paul Grundy, a physician and former VP of IBM who had recognized that the medical care costs paid by IBM in countries with a strong primary care base were much lower, even when controlling for the fact that many of those countries had national health insurance (because, in either case, IBM was paying the costs). This group, now renamed the Primary Care Collaborative, counts as members providers (both physicians and health systems), insurers, employers, pharmaceutical companies, patient-advocacy groups, and others. At the time of its creation, it was considered potentially revolutionary; with all of these major groups ostensibly buying into the benefits of primary care, the primary care specialties (family medicine, general internal medicine, general pediatrics) thought that there might finally be adequate recognition of their work. So, while of course being “Patient-Centered” is very important, it is the “Primary Care” that characterized these practice changes.

They were optimistic, but, unsurprisingly, overly optimistic. While having all those players in the PCPCC seemed like a good idea, but their agendas are not necessarily aligned with those of primary care; they can be summarized as “make money”. So they loved the “at lower cost” piece, and kind of liked the idea that maybe there was something magic in primary care that could lead to higher quality and greater patient satisfaction while spending less. Of course, it is not magic, but requires a coherent strategy to implement a structure in which the strengths of primary care were realized.

Dr. Starfield identified these strengths as the “4 Cs” of primary care:

• first-Contact care

• longitudinal Continuity over time

• Comprehensiveness, with capacity to manage majority of health

problems, and

• Coordination of care with other parts of the health care system

Starfield states ‘A primary care physician practices first-contact, comprehensive and coordinated care within the context of long-term person-focused relationships.’ (Starfield B, Oliver T. Primary care in the United States and its precarious future. Health & social care in the community. 1999;7(5):315-323). These characteristics allow the identification of which specialties are actually primary care (family medicine, general internal medicine, general pediatrics, geriatrics) and which are not. For example, it does not include either emergency medicine (yes for first-contact, no for continuity) or obstetrics-gynecology (many women’s primary physician, but scarcely comprehensive, dealing only with the reproductive tract).

The term PCMH (whichever “PC” you choose, or both) has not much been used lately. The more recent formulation has been the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost, even more recently expanded to include physician (or clinician) satisfaction and lower rates of burnout to make it the “Quadruple Aim”. But, according to the study by Colarsudo and summarized by Stevens, it hasn’t worked. Why?

There were two major flaws in the implementation of the PCMH (or, if you like, PCPCMH). The first is a national issue which needs to be addressed as a baseline, something which is necessary if not sufficient to ensure quality, is that the US does not have a universal health insurance system. (And, of course, everyone is not covered by IBM.) That means that whatever the benefits of primary care are (and I believe they are enormous), they will not be realized by the entire population, The fact that so many people have no insurance or have inadequate insurance makes the whole enterprise of trying to reform the American health system in any significant way impossible. When so many people haven’t got the money to access medical care (and in this regard, having poor quality insurance, with high copays and deductibles, is often worse than no insurance, despite what advocates for ACA / Obamacare claimed), they delay care. They not only end up in the emergency room rather than a primary care office, they end up there when they are much sicker, more likely to require hospitalization, and more difficult to treat and cure. Until this is addressed, any attempt to make any kind of major reform that is intended to improve the health of the overall population is doomed.

 

The other major flaw in implementing the PCMH was that the power players in US healthcare, the health systems and insurance companies, decided to try to realize the lower cost on the front end. They did not make the investments needed to ensure that primary care could function effectively to achieve what should be considered the two truly important aims, higher quality and greater patient satisfaction. As in every endeavor that seeks to make – or save – money, course upfront investment was necessary, but shockingly little was invested. For starters, there was a need for a lot more primary care clinicians than we currently have in the US to be able to ensure that people can have access, and that doctors have enough time with their patients and are not being asked to churn so many patients through. Without this you won’t be able to realize the long-term benefits of primary care identified by Dr. Starfield and others. You won’t get quality or patient satisfaction if people are being rushed through like cattle.

For there to be enough primary care physicians and other clinicians you have to start with paying them more without concomitantly asking them to “produce” more. Too few medical students are entering primary care, seeing both the heavy workload and relatively lower pay (also a marker of lower status). Concomitantly, to the degree that achieving these goals can be facilitated by other staff doing much of the work to maintain registries, remind patients of preventive care, etc., those staff have to be hired and trained. The wrong way to do it is how it has been done: requiring the clinician, rather than other staff, to enter all this data into the Electronic Health Record, using the most expensive and highly-trained members of the team to spend their time doing secretarial work instead of seeing patients. Indeed, primary care clinicians are now finding that they often spend more time charting than interacting with patients; this is a recipe for them to burn out and leave, not to increase either their satisfaction or that of their patients.

The solutions are clear – take care of the problems. More students need to choose to enter primary care, and this means that primary care clinicians have to be paid as much as other specialists (whether by paying PC more or paying the others less) and have workloads that encourage them to spend as much time as necessary with each patient listen to them, address their problems, and communicate effectively; that is, to provide them with quality care, to be able to deliver on the potential benefits of primary care. The cost savings come at the back end, from fewer unnecessary referrals to other specialists, from fewer emergency visits, and fewer hospitalizations. But they come after the necessary investments have been made and the systems have time to adjust. As in any other industry you cannot take your profit before you have produced your product.

And, of course, we need to ensure that everyone is insured, and well-insured. The best way to do this is to have everyone in the same insurance program, with the same benefits. Medicare for All. Everybody in, nobody out.

Reinventing Primary Care: Themes and Challenges

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My May 27 entry, Universal Coverage and Primary Care: The US needs both, focused on one article from the May 2010 issue of the journal Health Affairs. That article, by Barbara Starfield, (“Reinventing Primary Care: Lessons from Canada for the United States”) was just one of 65 articles in this issue that addressed the topic of “reinventing primary care”. The articles cover the gamut of the history of primary care, the problem of undersupply of primary care providers, proposals for increasing the number of primary care providers, analyses (such as Dr. Starfield’s) of the health systems of other nations’ that are based on primary care, proposals for how the organization and structure of primary care practices need to be changed, and case studies of models of practices and demonstration projects that have implicated innovative approaches to primary care delivery. Many of these practice changes are contained under the rubric of the Primary Care Medical Home (PCMH), which is also the abbreviation for the related Patient Centered Medical Home. Indeed, the Patient Centered Primary Care Collaborative (PCPCC), a coalition of major employers, insurers, providers, pharmaceutical and device makers, and consumers, uses both “PC”s in its name (one hesitates to say that it is thus very PC!)

One of the articles is in fact “The multistakeholder movement for primary care renewal and reform”, by Paul Grundy, et. al., specifically addresses and discusses this collaborative, as well as its proposals for change in the entire structure of the primary care delivery system. Grundy, who is vice-president for global health reform of IBM, is president of the collaborative. It has brought together these various stakeholders in recognition not only of the overwhelming data that shows systems that are built upon primary care are more efficient, more cost-effective, and lead to better health outcomes, but on the actual experience of IBM and other multinational companies. These companies find that their health costs, and the health (and thus lack of time off for illness) of their workers is dramatically lower in countries in which the health system is built upon a primary care base. It is actively involved in educating, advocating, and demonstrating the importance of developing such a base in the US.

Many of the other articles in the journal address changes that need to happen to allow the small (and, as I have pointed out, likely to stay too small even if there is a significant increase in production from our current paltry 16%) number of primary care providers to care for larger panels of patients, while maintaining or increasing quality of care, patient satisfaction, and efficiency. Two of these are co-written by Thomas Bodenheimer, MD, ‘Primary Care: Current Problems And Proposed Solutions”, by Bodenheimer and H.H. Pham, and “Transforming Primary Care: From Past Practice To The Practice Of The Future”, by D. Margolius and Bodenheimer. Another perspective, more from that of the individual physician than the overall health system, is Lawrence P. Casalino’s contribution, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday”

What is striking about these articles in the similarity of their recommendations. The recurrent themes include the need for multi-disciplinary teams of health professionals who all play roles in caring for patients, and panels of patients. This goes beyond the simple “nurses doing callbacks” to patients before, or instead of, the physician. It means that nurses provide the care that they can, that pharmacists and psychologists and social workers all are part of the team, communicating with each other but often operating independently. Group visits are another theme; often people with the same (or, in fact, different) conditions can benefit from being seen in a group. This can be for a more formal didactic session of patient education about their condition by a nurse, or pharmacist, or health educator, or physical therapist, or physician, or medications, or other treatments, often combined with a great deal of person-to-person interaction. There is more to this than efficiency; people actually benefit from the fact of being in a group, of sharing experiences, and ideas, and successes and failures.

Another important and recurrent theme is that of physician-patient interactions that do not involve face-to-face contact, but rather phone calls or emails. Again, this is not just a matter of efficiency for the physician; patients often have concerns that can be successfully addressed by one of these other methods that do not involve them having to take off work, drive a long distance, look for parking, and wait in the waiting room. A physician can be far more effective, and interact with a much larger number of people, if an afternoon consists of seeing a few in person, a much larger number by telephone, and an even larger number by email; a number of products exist that provide not only secure email communication, but provide a structure for the patient to supply information that will help the doctor (or NP, or nurse, or whoever on the team is most appropriate) provide the greatest help.

In his article, Casalino lists five reasons why a physician should see someone in person:
“(1) for a first visit; (2) when it may be necessary to engage in some physical maneuver for diagnostic purposes—such as palpating the abdomen, listening to the heart, or performing a skin biopsy; (3) for specific therapeutic purposes, such as injecting a joint; (4) when the patient has problems for which lengthy discussion would be helpful; (5) when for psychological or emotional reasons it seems better to see the patient face-to-face; and (6) when face-to-face visits are necessary to build trust.”
These are very good, but I would simplify it even more: the physician should see the patient face-to-face when either the patient or the physician think it is important.

The effectiveness and satisfaction from increased phone calls substituting for visits was clear in the late 1990s when capitation, rather than fee-for-service, was a dominant mode of payment (of course, at that time the internet was not yet developed enough for most people to be using email). To reprise, and to improve upon that process will, obviously, require a reimbursement system that does not pay only for face-to-face physician visits. This is another common theme to many of the articles in this issue. It is also not happening in most places. It is, however, a sine qua non for such practice reorganization. And increasing the primary care supply.

Which of these themes is the most important: increasing the supply of primary care physicians, reorganizing practices to become true Patient Centered Medical homes, utilizing all of the strategies above and more, or restructuring the way health care is paid for? They are all important, all related, and all dependent upon each other for success. What is not addressed in most of the articles in this issue of Health Affairs, however, is arguably the most important: ensuring health coverage for everyone. The work of the Patient Centered Primary Care Collaborative may go a long way to having a more rational delivery system for those with access, but as long as the same old hands, in particular the insurance companies but also the drug and device makers, are part of the decision-making process, they are unlikely to come up with a plan that truly covers everyone, single-payer, “Medicare for All”, or any other rational system. And without that, all the primary care reform is not going to really work. It is not only a moral issue (although that should be enough!); it is that the cost, in terms of work hours lost, unnecessary suffering, direct dollars spent on diseases that have advanced too far because people have delayed care, and ultimately worse outcomes, is unsupportable and unsustainable.

We’ve passed PPACA. Now it’s time for real health reform.
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