Primary Care 2.0: A Vision for a Transformative Solution

There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.

In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:

Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients (1).” Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967.

In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.

Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011.

They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement (3).”

And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.

Increasing access to insurance via exchanges and Medicaid expansion is zero sum game unless accompanied by increased access to primary care services.

That was a key lesson learned in Massachusetts’ reform circa 2006. And these three items from last week’s news suggest it’s getting deserved attention but no further clarity.

It’s obvious to all that a new solution is needed for primary care. But exactly what it should be is a vigorous debate. Our intramural conflicts are getting us no closer to a resolution. Consider…

  • Hospitals and health insurers are competing to employ community-based primary care physicians in the event that capitated payments become the dominant payment model. So private practices of primary care are fast becoming extent.
  • Primary care physicians and specialists are at odds over who owns their patients. Some specialists—oncologists, cardiologists, obstetricians, rheumatologists, psychiatrists and others—claim dual citizenship in primary care and specialty medicine.
  • Primary care physicians—general internists, family physicians and pediatricians– are waging war with specialists about how they’re paid. The Resource-based Relative Value Scale methodology used by Medicare and other payers to set reimbursement shortchanges “cognitians” in favor of “procedurists”—not surprising since the majority of physicians who weigh in on the model are specialists. (4)
  • And primary care physicians are fighting a holy war against advanced practice nurses and nurse practitioners that seek expanded scope of practice privileges, and non-conventional therapies (naturopathic medicine, alternative health, et al) believing they sell snake oil.

So finding a solution to accommodate increased demand for primary care services seems mired in the politics of the professions themselves.  What’s the answer?

To begin, the Affordable Care Act, though criticized, offers some important starting points…

  • Increased pay for primary care physicians: PCPs who see large numbers of Medicaid patients get paid at the higher rate paid by Medicare (just extended one year)
  • Increased supply of primary care services: additional medical residences in primary care, recognition of federally qualified health centers as medical homes, and additional training for nurses and allied health professionals
  • Stronger positioning as gatekeepers in demonstrations and pilot programs: the ACA’s patient centered medical home, accountable care organization, annual physicals for Medicare enrollees and incentives for employer wellness programs all require strong primary care front doors.

But these do not go far enough. Otherwise, the ranks of those enrolling in medical and nursing schools to serve in primary care roles would accommodate growing demand. But they’re not.

The future of primary care is not a repeat of the past; it is not a replay of Marcus Welby, MD.

Primary care 2.0 will be provided by teams of nutritionists, psychologists, dentists, ophthalmologists, geneticists, health coaches, nurses, and physicians who manage a population of several thousand assigned patients, coordinating their care, managing their access to and use of specialty and alternative health services over a long period of time.

Teams will compete for contracts. They will be paid on a capitated basis, with bonuses for clinical outcomes, user satisfaction, safety and savings against historic trends. Incentives, and risk, will be born by the team. Clinical judgement will be supported by decision support technologies and every patient connected by mobile health technologies used to prompt adherence to customized self-care plans.

Physicians will contribute their domain expertise as members of the team, not  necessarily as captains of every team so other competencies are better integrated in care management.

And results will be constantly measured against historic trends and best practice benchmarks with easy access by consumers and employers.

Primary 2.0 is a dramatic change from the status quo. How would we get there? Beyond what’s in the ACA, it requires four actions requiring commitment by policymakers and industry leaders:

1-Revamp “medical education” in primary care to a team based model. A six-year post-high school program for all primary care clinicians—nurses, physicians, and allied health professionals seeking careers in primary care—could replace the costly structure 8-year program in place today. Placement in the program would be based on competency-based skills assessed in the first two years of the program.

Acceptance into certified Primary Care 2.0 training programs featuring the team-based model would carry a full scholarship for 4 years of classroom and site-based training. Hospitals, health plans, or employers in addition to the federal government plan would pay scholarships, and contracts for service to scholarship awardees linked to measurable competency attainment and maintenance assessed annually.

To create the workforce necessary to Primary Care 2.0, a new, streamlined, team-based approach to their education linked to life-long competency-based learning is needed.

2-Create a liability safety net in primary care. The risks associated with insuring accuracy in diagnosing and appropriateness in treating populations with a myriad of signs, symptoms, risk factors and co-morbidities would be mitigated in the Primary Care 2.0 model by (1) binding hold-harmless arbitration for teams funded through malpractice premiums and victims funds, and (2) public access to Primary Care 2.0 teams’ clinical algorithms and outcomes used to manage their populations.

The expense for unnecessary tests and procedures to defend against liability claims exceeds $50 billion annually; premiums for liability and victim awards in Primary Care 2.0 could be less than $20 billion. Participants in teams would be protected from individual risk provided their team is vigilant about its adherence to team-assigned roles and competencies and policies, procedures and data is evident to demonstrate discipline in oversight. Creating a liability safety net is essential to Primary Care 2.0 risk taking and its savings could fund acceleration of its implementation.

3-Formalize and equip the primary care gatekeeper system. Millennials will support Primary Care 2.0; seniors less so. The generational preference about having “my doctor” is gradually giving way to consumer choices shaped by access, costs and the branding of an organization’s approach to medical care.

So policy makers are on safe ground to institutionalize a Primary Care 2.0 gatekeeper system not because it’s desirable to seniors, but because its value proposition in managing costs while optimizing quality and safety can be readily demonstrated. Requiring enrollees in Medicaid, Medicare, military health and federal health enrollees to maintain an active relationship with a primary care team via capitation is a start.

And funding meaningful use 2.0 and 3.0 investments for these teams would jumpstart their acceptance by clinicians. Ultimately, federal and state policies that establish gatekeeper status for appropriately operated Primary Care 2.0 teams would be transformative.

4-Promote the value proposition for primary care 2.0. Like Rodney Dangerfield, primary care has a chip on its shoulder, especially primary care physicians who feel little respect from their peers. A national campaign to educate consumers and employers about the value proposition of Primary Care 2.0 would be a necessary investment.

Last week, the nightly news focused on the Ukraine’s unrest. The other unrest is in primary care. A transformative solution is needed. Perhaps Primary Care 2.0 might be a start. Let’s discuss solutions.

Paul Keckley, PhD is an independent health care industry analyst, policy expert and entrepreneur. Keckley most recently served as Executive Director of the Deloitte Center for Health Solutions and currently serves on the boards of the Ohio State University Medical Center, Healthcare Financial Management Leadership Council, and Lipscomb University College of Pharmacy. He is member of the Health Executive Network and advisor to the Bipartisan Policy Center in Washington DC.  Keckley writes a weekly health reform newsletter, The Keckley Report, where this post originally appeared.

13 replies »

  1. Wow. First of all, I’m glad I spent the extra time to do a medical specialty so that I would never have to do primary care. Second, I am sooooo sick of practicing medicine even in my specialty — having a target on my back has gotten old. Third, you can’t pay a primary care provider enough to see a patient every 10 minutes, chart on an EHR designed by non-physicians guessing what a physician considers essential to know, make several hours worth of phone calls at the end of a day, and wear a target on his back.

  2. Agree here. But that only works for the “normal” people. The outliers cause the problems. 5% consume 40%. 20% consume 80%. Somehow we need to provide much more cost effective care and improve behaviors for the top 20% consumers. A sizable portion of these are masters of poor health promotion, non-adherence to medical advice, seeking expensive testing, and over-utilization. It is fascinating that the very people that seek advice most, often are the first to disregard it. I wish I knew the solution to this.

    There are 3 solutions to the problem:

    1. work harder to prevent expensive chronic disease. Hopefully we are doing a better job here.

    2. reboot our approach to make expensive chronic disease care cheaper. This may prompt some very tough decisions regarding futility. Can we really afford not to make these tough decisions?

    3. Provide an inexpensive outlet for over-utilizers or begin to deny care. I doubt you can educate these people effectively.

    I doubt any new-fangled 2.0 approach can be effective without accomplishing these basic solutions.

  3. Primary care cannot be done by people with lower levels of training than an MD, or at least a competent ARNP or PA. The reason is that primary care’s role is NOT as a gatekeeper. To suggest that is to repeat the fatal errors of prior wonks who have never longitudinally observed a good PCP’s contribution to a community.

    The meaning of primary care is a relationship in which the patient/consumer trusts their advisor about what tests and procedures they do not need and should not pursue. This can only occur if the patient ahs confidence n the diagnostic and communication skills of their health care provider.

    This is not mechanistic. It is not scalable. It is not a great business model, but it will save the system.

  4. It was screwed up by government long before EMTALA in 1986. The big payors inflicted one-sided discounts on all providers, making the little guu unprotected by basic fairness. We as providers by law MUST charge everyone the same thing. The big guy s decreed they only pay a percentage of THEIR allowable plus any allowed co-pays.

    The fact is thanks to government there exist no market in health care. It is all rigged by people very zealous and very dogmatic and very incompetent.

  5. Agree that there is much regulatory waste.

    However, regulation often arises because healthcare is an imperfect (very imperfect) market.

    If it was all so rosy EMTALA would not have been passed.

  6. No one said they would not pay their bill. If we were not sucking all their money away for stupid beaurocracy they could pay for healthcare. If charges were honest and paid 100% by every payor, then everyone uninsured would pay less.

  7. to summarize:

    “doctors are too expensive . We need the “team” to care for you most of the time. they’re cheaper, and mostly adequate.
    we’ll collect a lot of data. And employ more admistrators to look at all the data. And all you patients will like this, and be healthier too.”

  8. Stated differently, the patient is sovereign!

    But this same patient who wants to be left alone will be the first to call 911 for chest pain and expect excellent services in the emergency department.

    I love the “live free or die” motto. But I’m yet to meet many (any?) who have not called emergency services on the principled grounds that they had not purchased health insurance.

    So it’s a case of “live free and stop my from dying, free or subsidized”.

  9. What a crock.

    No one can agree because they cannot enslave the patient. If the silly patient would just do what you tell them to do it would be easy. But you can;t and they don’t.

    All these plans are failing to center around the patient, who does not care for all this prevention or intrusion or fear-mongering.

    The patient is, will be, and has always been in charge of his utilization of health care.

    The well patient will never need or want all this crap and most people are well.

    Finding a new package for cutting services while increasing premiums will not impress the patient. Thanks to ObamaCare the patient just wants his money back for him to spend as he sees fit.

    He is right!

  10. Paul,

    Admittedly the problem with the first generation of PCMH pilots (call them version 1.0) is that groups like NCQA, JACHO and other accreditation bodies seemed to write the “specs” for the medical home rather than medical professionals with experience managing “high performing” practices.

    But the ball game with respect to PCMH is only in early innings. Should PCMH proponents come to realize that it is the softer elements such as effective patient-centered communication skills (and not HIT or embedded care coordinators) that lead to better outcomes, lower costs and better patient (and physician experiences) we may still realize the promise of PCMH.

    Steve Wilkins, MPH
    Mind the Gap

  11. “A six-year post-high school program for all primary care clinicians—nurses, physicians, and allied health professionals seeking careers in primary care—could replace the costly structure 8-year program in place today.”

    Currently a primary care physician completes; 4 years of College, 4 years of Medical School, and at least 3 years of Residency. And that can be replaced by 6 years post high school? So that means that current practicing Physicians wasted 5 years of education! (“5 years of college down the drain.” John Belushi, Animal House)

    But can’t this principle be applied to other fields?
    – Mr. Keckley has a PhD, most of which take at least 4 years post college. Why not just give a PhD to people straight out of college and cut out 4 years?
    – Similarly a lawyer needs 3 years of Law School. Why not cut that to 3 years INSTEAD of college? Extra credit for watching Judge Judy on TV!
    – MBA – 2 years out of high school with extra credit for; cutting grass, babysitting and a paper route!

  12. Bobby Gladd,

    Good point, and Keckley also proposes “annual physicals for Medicare enrollees and incentives for employer wellness programs all require strong primary care front doors.”……in spite of lack of evidence in randomized control trials that these provide any value to patient outcomes (as well discussed on this site).

  13. “non-conventional therapies (naturopathic medicine, alternative health, et al) believing they sell snake oil.”

    That is ABSOLUTELY the case. See the voluminous work at ScienceBasedMedicine.org