It's widely acknowledged that the U.S. primary care system faces unprecedented challenges and that the Affordable Care Act is essentially a menu of potential fixes. But exactly what are the obstacles to making those changes? What can be done about these obstacles? And why aren't we doing that faster and more broadly?
"Culture," says Joshua Metlay to that last question. "We have a very historic model with the doctor in the center."
"Inflexible payment systems," says Dan Polsky. "Current insurance rules make it difficult to experiment with innovative approaches
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Joshua Metlay, MD, PhD, University of Pennsylvania Professor of Medicine at the Perelman School of Medicine and LDI Senior Fellow.
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Dan Polsky, PhD, MPP, University of Pennsylvania Professor of both Health Care Management at the Wharton School and Medicine at the Perelman School of Medicine, Executive Director of LDI.
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Karin Rhodes, MD, MS, Director of the Center for Emergency Care Policy Research in the Department of Emergency Medicine at the Perelman School of Medicine, and LDI Senior Fellow.
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David Grande, MD, MPA, University of Pennsylvania Assistant Professor of Medicine at the Perelman School of Medicine and LDI Senior Fellow.
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Evan Fieldston, MD, MBA, MSPH, University of Pennsylvania Assistant Professor of Pediatrics at the Perelman School of Medicine and LDI Senior Fellow.
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Jaya Aysola, MD, MPH, University of Pennsylvania Assistant Professor of Medicine at the Perelman School of Medicine.
that require new sorts of reimbursements."
"Patient preferences," adds Karin Rhodes. "Ultimately, consumers need to be re-educated to understand they don't need a doctor when a nurse practitioner will do."
Metlay, a Professor of Medicine at the University of Pennsylvania's Perelman School of Medicine; Polsky, a Wharton School Professor of Health Care Management; and Rhodes, Director of the Center for Emergency Care Policy Research at Perelman, are all part of a 16-member Penn Health Policy Workforce workgroup. Formed a year ago, that panel is exploring how the human infrastructure of health care delivery can be better organized, motivated and managed. Nine members of this team recently met for a roundtable discussion focused on the perplexing matter of primary care delivery.
'Not sustainable' That issue's essential situation seems well summarized in a recent New England Journal of Medicine analysis that concluded: "Adult primary care as currently organized is not a sustainable enterprise." One reason is that the number of patients requiring care is expected to skyrocket as millions of the previously uninsured are granted coverage under the ACA and, as similar millions of Baby Boomers age further into chronic infirmities.
There's also the question of the adequacy and quality of care now being delivered. A University of California, San Francisco study published in the October issue of the Annals of Family Medicine says, "the average primary care physician's panel size is too large for delivering consistently high quality care." It cites previously published estimates that a single physician with an average 2,500 patient panel would have to work 21.7 hours a day to provide patients all the acute, chronic and preventive care now recommended by government and professional standards organizations.
Lower-level skills In addition, the UCSF researchers' models estimated that up to 77% of the preventive care and 47% of the chronic care traditionally provided by physicians could be delegated to lower level non-clinicians.
"There is a shortage of primary care physicians that is not likely to be rectified in the next ten years," said Perelman Assistant Professor of Medicine, David Grande, who moderated the Workforce workgroup roundtable. "So, the issue confronting us is to rethink how individual doctors can expand the number of people they see and more intensively manage the care of their high-risk patients."
But attempts to do that inevitably encounter wide variation and puzzles of unintended consequence across primary care settings. For instance, physicians who own their own practice have a different set of interests than those employed by hospitals. "I know one practice in Philadelphia owned by one person who is very interested in expanding his business," said Perelman School of Medicine Assistant Professor of Pediatrics Evan Fieldston. "He was on an aggressive growth strategy but patients are now complaining that they can't get in and that the more personalized experience they once had wasn't there anymore."
Beyond 'bricks and mortar' "In thinking about providing more care with the same number of physicians, we can explore multiple dimensions," said Metlay. "One of those is the physical space capacity issue -- how much more primary care can be delivered in a more distributed and decentralized fashion? How could we push the 'bricks and mortar' boundaries to achieve what might be tremendous additional capacity in the system?"
Fieldston agrees. "We still have a very old fashioned view that 'medical home' means a stationary place on a concrete foundation, but others have said a medical home is 'meta data following a patient.' Why isn't the medical home accessible in different places and through different kinds of linkups -- so patients can go to primary care, the ER, retail-based clinics, or specialists and their records follow them wherever they go and always back to the primary care provider?"
"Yes," said Rhodes, "we hear so many primary care doctors saying, 'I didn't even know my patient was in the ER.'"
Medical home concept The "patient-centered medical home" -- a big part of any discussion about the future of primary care -- is just one of the team-based care concepts that are core pillars of the ACA's vision for transforming health care delivery. Basically, it's a primary care practice expanded into a medical team responsible for coordinating all of a patient's care from all sources -- a dramatic departure from the fragmented "fee-for-service" model in which no one is responsible for overseeing and documenting the "whole" patient's wellness and medical needs.
In the medical home model, a physician and nurse practitioners oversee a team of physician "extenders" and other medical professionals (dietitians, pharmacists, behavioral health specialists, health educators, etc.), all working at the top of their license to take over many of the clinical duties previously performed by the doctor. This broadens the team's ability to treat more patients simultaneously and, theoretically, increases the amount and quality of care each patient receives.
Less than enthusiastic There are growing numbers of medical homes now operating across the country; The Blue Cross Blue Shield Association alone has a variety of experimental models running in 47 states. But many primary care physicians are less than enthusiastic about reinventing their businesses to add and empower nurse practitioners and physician assistants to share in their doctor-patient relationships.
"As we discuss this, we need to be specific," Fieldston said. "Physicians in organized medicine have long resisted efforts to broaden the scope of practice and allow for reimbursement of other health care providers for many reasons, including concerns for quality as well as protecting their own interests. I mean we should be frank about that."
Many primary care physicians may also not have the financial depth to hire advance practice nurses, said Rhodes. "A young nurse practitioner gets out of training and wants to go into primary care, but can't find a job until a cardiologist hires her. Specialty physicians see the value of a 'physician extenders' because those doctors are charging more for their time. But most primary care doctors aren't making a lot more than a nurse practitioner and can't afford to hire one solo; they have to be in a larger group practice to leverage that."
Inadequate payment models Beyond that, said Perelman Assistant Professor of Medicine Jaya Aysola, many medical home-like practices that have successfully altered their culture and worked out team care protocols are still stymied by the lack of an adequate payment model. "They may have licensed 'physician extender' staff members in place to augment the physician's role and expand patient capacity and care, but there's not an independent billing structure to cover those services in the current fee-for-service model."
"If payment reform aspects of the medical home don't kick in and we don't scientifically test them," said Aysola, "we're never really going to expand much beyond what we have."
Polsky pointed out that altering a specific region's insurance compensation rules is very difficult. "Because of regulations, you almost need to get the governor of the state to make that happen," he said. "Maybe if you go into a market where there's a single dominant insurer there would be more potential for innovation."
Patient preferences Yet another obstacle is that the patients themselves may not be comfortable with new logistics preventing them from dealing directly with their doctor on each visit.
"To some extent," said Grande, "we're still a culture within both the medical profession and general society that thinks everyone needs a doctor all the time."
Fieldston suggests we look at dentists' offices for an alternative model. "It's the opposite," he said. "The center of a dentist wellness visit is the hygienist; only if the hygienist sees something that's a concern does it go up the chain to the dentist."
"In fact, people often don't need to see the dentist at all," agreed Metlay. "That's just a billing code. So, by analogy, maybe the 25-year-old doesn't need her doctor; most don't. She simple needs someone who is qualified to handle her particular issue."
"Primary care patients can be retrained," said Rhodes. "We've already seen that in OB/GYN. You may have a personal physician, but the doctor who delivers you when you go into labor is the doctor on-call. We trained women and families to understand and expect that as a team practice. I don't see why, over time, we can't do the same thing for the medical home model so that a 25-year-old knows everyone there cares about him and what's really important is that he's getting the episodic care that he needs."
Other innovative alternatives Beyond medical homes, there are other innovative care models that could help extend staff and build broader care capacity said Rhodes. "One of those is group visits," she said. "Pediatricians already do group wellness visits with moms and babies. My research team has run focus groups for asthmatics and those patients love getting together to talk about their disease. They educate and support each other -- but it is also helpful to include a knowledgeable health care provider who can counter some of the myths and answer patient questions. I think disease-specific group health education would be an interesting model to test out using nurse practitioners and other physician extenders."
"Another approach worth investigating involves rethinking our approach to acute care," said Rhodes. "Why can't emergency departments or urgent care centers provide care coordination and communicate with the primary care provider about the acute care visit? This would be much easier if they share the same medical record. Really sick people can be triaged for immediate treatment and hospitalization and less sick patients can be treated and have a follow up appointment arranged with their primary care provider with documentation of the treatment provided in the shared medical record. So, when a patient comes in with an exacerbation of a chronic condition like diabetes or congestive heart failure, they can be treated and then appropriately linked back to their medical home for further medication management, dietary counseling, diabetic teaching or smoking cessation."
"We have a lot of resources in this country," said Rhodes. "And if they were better organized I think we could deliver better care at lower cost to more people."
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Hoag Levins is a journalist and managing editor of The LDI Health Economist. hoagl@wharton.upenn.edu
