Trendspotter: More Radical Change Is Needed to Save Primary Care

The importance of primary care in restructuring our healthcare system is widely recognized. As a current article in Health Affairs points out, avoidable hospital admissions for asthma and diabetes complications in the U.S. are twice the average for advanced countries, and that isn’t because the United States has a greater prevalence of these conditions. It’s because people have better access to primary care in those countries. Since their chronic diseases are treated at an earlier stage, they have fewer complications and hospitalizations.

The Health Affairs article, authored by leading proponents of primary-care reform, points out that employers, insurers, government agencies, physicians, and medical societies have coalesced into a movement that’s trying to save primary care.

For example, the Patient Centered Primary Care Collaborative, headed by Paul Grundy of IBM, one of the paper’s coauthors, has been a leader in the medical home movement aimed at transforming primary-care practices. Many other employers and health plans are funding medical home pilots, and Medicare is planning a demonstration of the concept. North Carolina Medicaid’s successful care coordination project, which saved the program $400 million in 2008, has spurred similar efforts in many other states. And the new federal reform legislation will raise primary-care physicians’ reimbursement in Medicaid programs to Medicare levels, at least in 2013 and 2014.

This combination of public and private initiatives will undoubtedly help shore up primary care. But it’s unclear whether these efforts will be enough to meet the unprecedented demand for primary care starting in 2014, when 32 million people who are currently uninsured will gain access to coverage. The other big issue is whether the ideas currently being advanced to improve care coordination and the quality of care will have a significant impact unless there’s a fundamental shift in how we finance and deliver care.

The coauthors of the Health Affairs piece freely admit that the transformation they envision will require a lot more funding and a change in how doctors are paid. This won’t be easy. When Medicare recently increased primary-care fees while reducing certain specialty and imaging payments they note, some specialty societies went ballistic.

Yet much larger reimbursement shifts would be needed to make primary care more attractive to medical students. A recent study found that primary-care doctors make less than half as much as cardiologists do during the course of their careers, and the earnings of 13 other specialties dwarf generalist incomes to an even greater extent. A small bump in Medicare reimbursement for primary-care physicians or raising their Medicaid fees to Medicare levels won’t close this gap.

I also wonder whether it’s possible to transform most small primary-care practices into medical homes in the current environment. As most of you know by now, becoming a medical home requires practices, not only to adopt and use electronic health records, but also to extend their hours, introduce open-access scheduling, form care teams, communicate with patients by e-mail and phone, and, most important, coordinate care across the healthcare system.

Some small practices have made progress, but many others lack the resources and the know-how to become medical homes. Moreover, as the Health Affairs article points out, some practices run into problems when they try to get cooperation from specialists and hospitals in their community. “In that case, primary care renewal may need to be linked to other reforms, such as accountable care organizations, to reorient incentives and values across all health care tiers,” the coauthors write.

Accountable care organizations (ACOs) are envisioned as assemblages of hospitals and physicians that would take financial responsibility for certain components of care or might even take global risk. It’s hard to find examples of ACOs, however, beyond large health systems and IPAs that are already structured to share financial risk. Whether small practices outside of California would be willing to surrender some of their financial and clinical autonomy to join an ACO is simply unknown at this point.

But a good guess is that for this approach to work, the business environment would have to become so harsh that small practices would believe they had no choice but to join with their colleagues.

This is exactly what happened for a brief time in the 1990s, when physicians and hospitals thought that capitated managed care was about to sweep the country. Of course, when that didn’t happen, they slid right back into their old independent, fee-for-service arrangements, and primary care resumed its decline.

Whether it will be any different today depends mainly on what payers do. But indications are growing that employers and the government want a radical change.