By Mona Safarty
HEALTH AFFAIRS recently released a new issue called Reinventing Primary Care during a well-attended press conference at the National Press Club on April 10, 2010 in Washington, D.C. To highlight the importance of the topic, HHS Secretary Kathleen Sibelius led off with an update on the implementation of health reform. Authors of many of the articles in the issue gave brief presentations summarizing key points from their work.
In the first panel of speakers, Larry Casalino from Cornell University said that substantial restructuring is the only way the nation can provide enough primary care services to accommodate the new insured population. He believes only one third of current appointments require in-person face to face care. He suggested that other patient visits could be supplanted by communication via e-mail, telephone, or dealings with other office staff; and that medical offices encourage providers to communicate this way.
Kavita Patel and a group of researchers reviewed differing models of patient centered medical homes. They found differing definitional criteria and conclude that improved reporting measures are needed, as is information on how to structure payment. They draw attention to a model in North Carolina that was effective with a large Medicaid population and succeeded in decreasing emergency department use and hospitalization. Other successful models have been developed by Group Health -- and in North Dakota.
Paul Grundy of IBM is a proponent of the patient centered medical home (PCMH). He contends that businesses that purchaser health care want PCMHs for their employees. He emphasizes team care that is integrated not fragmented. Medical schools must take the responsibility for training the doctors to deliver such care. He described the transformations of the Spanish and Danish medical care delivery systems, which emphasized primary care and have made dramatic progress in reducing duplicative and unnecessary visits and improving outcomes. Seventy percent of Danish medical encounters are now asynchronous. The reimbursement system supports a strong relationship between doctor and patient rather than voluminous diagnostic testing.
Katie Merrell of Social and Scientific Systems said payment incentives will shape the delivery system. There are many possible ways to shape the reimbursement system. She spoke in favor of integrating quality, payment and recognition within the patient centered medical home.
Troyen Brennan of CVS Caremark reported that retail clinics are now accredited by the Joint Commission on Organization of Hospitals. They employ only Board Certified nurse practitioners. He estimates there will be a deficit of 40,000 primary care physicians by the year 2020. He said currently 50 percent of children and 60 percent of adults have no primary care physician. Retail clinics seek to coordinate with the primary care doctors for each patient.
Eric Holmboe of the American Board of Internal Medicine Foundation discovered through his research that teams are not explicitly defined or recognized in medical practice, and it is not clear how they work. His group found little inter-professional teamwork. Other staff collaborated with each other but not with physicians. Patients often feel disoriented and "in limbo" and do not benefit from shared decision making.
Expanding the focus on teams, Joanne Pohl spoke about nurse practitioners who graduate at the rate of 8,000 per year, James Cawley spoke about physician assistants; and Marie Smith spoke about why pharmacists belong in the medical home. She said that at her academic institution, they teach what a team is. A team involves clearly defined roles; everyone knows what the roles are.
The last panel of speakers presented practice profiles. Susan Edgman-Levitan from Massachusetts General pointed out that there is virtually no training out there about how to make changes. She asked: Where is the patient in the medical home? Medical care looks to them like it is all done to them. They don’t know what this new model is supposed to do. Richard Larsen, an internist from Pennsylvania who participated in the chronic disease collaborative, reported that his practice hired a health educator who trains their medical technicians so they can do self management exercises with patients.
Eric Larsen of the Group Health Research Institute spoke about their successful efforts at practice change. They looked carefully at health delivery in Denmark and came up with an entirely new model. They decreased clinician panel sizes, increased visit slot times from 20 to 30 minutes, and started paying for the time that physicians spend making phone calls, sending e-mails, and writing letters. Their two-year results with this approach were so encouraging that they expanded to all 26 of their clinical sites.
Alice Chen from the Family Health Center at the University of California at San Francisco discussed their work to change their computerized referral system. They reduced the time to referrals and warded off unnecessary referrals by assuring better communication back and forth between specialist and primary care doctors. Karen Nelson, from the UNITE HERE Health Center funded by 32 unions, shared her perspective on training people to work as a team, and promoting team members to work as health coaches.