Covering primary care in the 21st century
Felice J. Freyer
By Felice J. Freyer
Primary care is where the rubber meets the road when it comes to health-system changes. Whether you want to reduce emergency room use, better manage chronic illness or boost immunization rates, primary care providers must be the driving force. And yet what the wonks call “the primary care infrastructure” has never been more fragile. For reporters, this means a rich trove of stories on issues affecting the lives of everyone.
The shortage: There are not enough primary care doctors to meet current needs, never mind the expected demand (PDF from the Association of American Medical Colleges) as more people obtain insurance under Obamacare. [See "Changes coming to health care workforce ripe for coverage."]
Medical education: Only a third of medical students start out with an interest in primary care. Medical school tends to further steer doctors-in-training away from primary care. Even for those who remain committed, the curriculum often lacks training in the skills they need (such as diagnosing routine problems and working with other providers).
Money: Primary care doctors earn significantly less than doctors in other specialties but often graduate with heavy medical school debt. The fee-for-service system rewards tests and procedures but doesn’t pay for the phone calls, discussions and care coordination that are essential to good primary care. And yet, the evidence suggests that investing in primary care lowers costs overall.
Other professions: Nonphysician providers, such as nurse practitioners and physician assistants, can perform many aspects of primary care and are seeking a greater role. But even though there’s plenty of work to go around, turf wars continue to erupt. (For example, the American Academy of Family Physicians opposes allowing nurse practitioners to practice independently.)
New models: Many primary care practices are adopting new models of care that emphasize teamwork, technology, improved access and evidence-based care. Some have worked with insurers on new payment methodologies that reward quality and prevention.
Access: How’s the access to primary care in your community? Are practices accepting new patients? How long do people wait for appointments? What’s the ratio of primary care doctors to specialists? Keep in mind that access involves more than finding a provider to call your own — it also involves being able to see that provider when you get sick, which isn’t necessarily going to happen during business hours
Team-based models of care: Are there patient-centered medical homes (PCMH) in your community? How many patients do they serve and what level of NCQA accreditation have they received? Are they making a difference? (Caution: Ask PCMH advocates for data backing up their assertions of effectiveness, and look closely at the source of the data. Not all PCMH practices are equally effective.) Have any medical practices in your area entered into agreements with insurance companies to move away from fee-for-service, such as pay-for-performance, bundled payments, global payments or capitation?
The solo practitioner: Are there one- or two-doctor practices in your community? How are they keeping up with the new demands for evidence-based care and electronic medical records? Will solo practitioners eventually all be forced out of business? In the move to complex, team-based care, is something valuable being lost? A small nationwide movement promotes “micropractices,” in which one doctor works alone, with little or no staff.
Medical education: If there is a medical school in your area, ask what it’s doing to address the primary care shortage. What percentage of its graduates go into primary care? (Caution: Don’t take these figures at face value: many graduates who say they’re going into a primary care specialty end up choosing a subspecialty such cardiology or pediatric endocrinology.) Are there any curriculum changes in the works to improve primary care training?
Transparency of patient records: A new trend gives patients easy, online access to their complete records, including the doctor’s notes and lab-test results. Proponents believe such access enhances patient engagement. Others are skeptical, saying it could lead to misunderstandings, confusion and fear. In some states it’s not even legal for patients to directly obtain the results of their lab tests.
Removing the barrier between physical and mental health: Another new trend has mental-health professionals working in physicians’ offices. A doctor who suspects a patient is clinically depressed or addicted can immediately give the patient access to help. The mental-health professional can also help patients with behavioral challenges important to their physical health, such as losing weight or getting exercise.
Retail clinics: Most stories about these mini-clinics located in drug stores and supermarkets have focused on how patients love the convenience. But how do Minute Clinics and other retail clinics fit into the rest of primary care in your community? Do they meet a need or do they further fragment health care? Are patients getting appropriate follow-up? Are the clinics adequately regulated? How do local physicians regard them?
Nonphysician primary care providers: What is the role of physician assistants and nurse practitioners in your area? What do your state’s laws say about what they can and cannot do? Are physician practices employing them effectively? Can such providers practice independently and how’s that going? Are there moves afoot to change the scope-of-practice laws? Are there concerns about these professionals’ role – people who think they have too much independence or people who think they’re under-used?
Hospital ownership: Hospitals are buying up physician practices, including primary care. But as they enlarge and diversify, hospitals become more powerful, able to command higher payments from insurers. Some also tack on a “facility fee” to ordinary office visits at the practices they own. Does hospital ownership of physician practices enhance efforts to prevent hospitalization or does it undermine the cost-saving role of primary care? Does it affect patient care?
Primary Care Progress, an advocacy group with chapters at medical schools and other health professional training schools, working to change how care is delivered and how providers are trained. The group offers a fact sheet on primary care.
The Patient-Centered Primary Care Collaborative: A D.C.-based organization that promotes the PCMH concept and tracks the outcomes of pilot projects.
“The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care,” a report from the National Governor’s Association.
“Changes in Medical Students' Views of Internal Medicine Careers from 1990 to 2007.” Archives of Internal Medicine 2011
“The Developing Vision of Primary Care.” NEJM 2012
Examples of innovative primary care practices:
WellMed, Austin, Texas
SouthCentral Foundation, Alaska
Coastal Medical, Rhode Island