"Bold changes are needed in how the United States delivers and pays for primary care if the key goals of national health reform are to be achieved" according to the health policy journal Health Affairs, which today released a thematic issue devoted entirely to the crisis in primary care. (The complete articles are available only to subscribers, but Health Affairs' blog has a good summary.)
I have spent much of the day reading the journal - 47 articles, and a combined three hundred pages of text. My "take-home" messages from the articles:
1. There is a broad consensus that primary care is in crisis. (As an aside, I remember that some said that ACP was being alarmist when in 2006 we predicted that primary care was heading for collapse. Now it has become the conventional wisdom.)
2. The solution is not as simple as training more primary care physicians and paying them more, but to re-invent primary care itself. Susan Dentzer, the editor of Health Affairs, writes that "primary care is maddeningly struck in a by-gone era." Joel Howell reflects on the past and future of primary care, and that the question is not "Will primary care be re-invented" but rather, "How will primary be care be re-invented?"
3. The prescription to re-invent primary care recommended by most of the authors is team-based primary care, usually around a Patient-Centered Medical Home - although several of the articles discussed the need for more rigor in defining the necessary elements for PCMHs to be successful, the best mix of payment incentives needed to support them, the importance of putting more emphasis on features that matter to patients. Yet the articles recognize the potential of PCMHs to improve care and make primary care more attractive to clinicians. Two years after into adopting the PCMH model, the Seattle-based Group Health Cooperative reports on marked improvements in patients' experiences, quality and clinical burn-out.
4. Team-based care means much more than physicians. David Margolius, a medical student at Brown, and Thomas Bodenheimer, professor of family medicine at UCSF, write that "a transformed primary care practice must redefine the physician role such that the physician no longer sees all patients assigned to the practice but as a leader for a well-trained, highly functioning primary care team." Another article advocates for "unleashing" nurse-practitioners' potential to deliver primary care and lead teams - including eliminating state "barriers" to independent practice. Christine Sinsky, MD, FACP, writes about how her Iowa practice has developed a team-based model of care with community-based NPs. Lawrence Casalino argues that the typical workday of primary care physicians needs to be completely transformed, so that instead of seeing a high volume of patients, they would spend more time with those who actually need it.
5. Most of the articles agree that primary care physicians need more pay. One article suggests that narrowing the gap between primary care physicians and other specialties would require increases in primary care physicians' practice incomes, or substantial reductions in specialists' incomes, or both, of more than $100,000 per year. But others argued that primary care clinicians should be paid more only for doing things differently than they do today - that is, delivering patient-centered team-based care that achieves better outcomes.
The attention to the primary care crisis and potential solutions is a good thing. I wonder, though, whether primary care physicians "in the trenches" really want to have their practices re-invented. Most physicians, in my experience, are rugged individualists, and resist the idea of practicing as a member of a team. Moving away from what one article calls the "tyranny" of the 15 minute office visits sounds like a good idea - but figuring out how to get there, and sorting out the respective roles of every member of the team, is another thing. And no matter what, we need a viable payment model that supports, sustains, and nurtures the value of primary care internal medicine.
Today's question: Should primary care be re-invented? How?