David S. Meyers, MD; Carolyn M. Clancy, MD
Disclaimer: The opinions expressed here are those of the authors and do not reflect the views of the Agency for Healthcare Research and Quality.
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Current Author Addresses: Drs. Meyers and Clancy: Agency for Healthcare Research and Quality, John M. Eisenberg Building, 540 Gaither Road, Rockville, MD 20850.
Meyers D., Clancy C.; Primary Care: Too Important to Fail. Ann Intern Med. 2009;150:272-273. doi: 10.7326/0003-4819-150-4-200902170-00009
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Published: Ann Intern Med. 2009;150(4):272-273.
The U.S. primary care system is struggling. Increasing demands and expectations, coupled with diminishing economic margins, have created a challenging work environment. Analysts warn of increasing attrition in the current workforce and diminishing recruitment of new physicians to primary care (1).
As the new Obama administration arrives in Washington, policy prescriptions for health care reform are being dispensed from every side. Many of them emphasize the importance of revitalizing the nation's primary care system. As a foundational element of the health care system, primary care is needed to improve quality, increase access, and contain costs (2). These are the principal goals of health care reform.
A key to the sustainability of primary care will be payment reform coupled with innovative quality measures and value-based purchasing. Although challenging, payment reform seems possible within the larger context of national health care reform, particularly because Congress must act on Medicare physician reimbursement this year. Payment reform alone, however critical, won't revitalize primary care. Payment reform is a maintenance medication and primary care is in need of an immediate rescue. The U.S. primary care system needs a stimulus package that, such as plans for an economic stimulus package, focuses on infrastructure.
As the article by Pham and colleagues (3) in this issue suggests, a primary care infrastructure investment must address the substantial challenges of care coordination in primary care. By using a survey of more than 2000 primary care physicians who participated in the Community Tracking Study, the authors calculated the number of other physicians and practices that a primary care physician's Medicare patients visit over the course of a year. Their sobering conclusion was that a typical primary care clinician must coordinate the care for their Medicare patients with 229 other physicians working in 117 different practices. Although rural physicians work with slightly fewer peers, those in smaller practices and those treating more patients with chronic illnesses work with even more. Although most practicing clinicians already know that coordination is a big challenge, Pham and colleagues' article does a good job of quantifying and detailing the size of the problem. Given the conservative study design choices that the research team made—they do not include primary care physicians' coordination with nonphysician therapists, educators, psychologists, and community partners, and do not include the vital care coordination with patients and their families—the true scope of the issue is even larger. Although previous work by this team and others (4) has demonstrated that Medicare beneficiaries often are cared for by multiple physicians in multiple practices, the article provides valuable insight into the scope of the care-coordination challenge from the perspective of the primary care physician.
The functions of primary care, including care coordination, cannot be accomplished by the lone physician, no matter how dedicated. Primary care teams are a central tenet of the patient-centered medical home, a comprehensive model for delivering primary care. As primary care practices are redesigned to take advantage of the complementary skills of a variety of team members, care coordinators will take their place as indispensable members of the team. Current medical home demonstration projects across the country are experimenting with divided payment models that incorporate per-patient per-month capitated fees to enable practices to make investments in nonphysician team members. A substantial hurdle facing these projects is the costs of transforming the typical small primary care practice into a medical home. Even if payments are robust enough to support the ongoing expenses of a primary care team, they are unlikely to cover the substantial 1-time costs of redesigning workflow, reconfiguring offices, recruiting and training new staff, and retraining the current workforce. If the potential of the medical home is confirmed, our nation must be prepared to make an investment to support the transformation of primary care practice.
Once we begin to examine how to assist primary care practices in transforming into fully functioning medical homes, we find that few small- or medium-sized practices (more than 75% of primary care practices in 2006 employed 5 or fewer physicians ) have any infrastructure to support quality improvement. Small primary care practices are unable to support full-time quality improvement officers, chief information officers, social workers, health educators, mental health professionals, and care coordinators. A community could support this enterprise. Therefore, a community-based health care extension service may play an important enabling role in the transformation and sustainability of primary care. The functions of these community-based and -managed teams would be to:
1. Provide small, local primary care practices with the services of care managers, social workers, health educators, and other professionals.
2. Serve as connectors linking local primary care practices to existing community resources, such as social services, mental health services, and public health resources and programs. A community-based health care extension service would be more effective if its mission included mobilizing, organizing, and coordinating the local on-the-ground public resources, such as agencies on aging, substance abuse services, and family services, and connecting them with primary care practices and patients.
3. Provide primary care practices with quality improvement technical assistance, including practice redesign, assistance with the adoption of health information technology, and information on local best practices and national evidence-based practices and guidelines.
4. Partner with academic centers and primary care practice–based research networks to coordinate practical clinical trials to answer practice-informed research questions.
The model of shared community-based, practice-controlled resources already exists in North Carolina. The Community Care of North Carolina initiative has demonstrated success as measured by improved quality of care, cost savings, physician satisfaction, and scalability (6, 7).
Primary care health information technology infrastructure investments could also produce dividends in the form of improvements in quality, safety, and better care coordination. Pham and colleagues correctly note that the electronic exchange of health information between physicians is currently limited. However, electronic health information exchange, electronic health records, personal health records, and asynchronous electronic communications all offer potentially efficient and effective ways to ensure that the right information is available to the right people at the right time to improve the coordination of care in the United States. Because currently available health information technology, even if more widely adopted, would not fully achieve our goals for quality, we must aggressively invest in next-generation systems and tools and plan for their deployment.
We would be wrong to spend time debating which needs to come first: payment reform, attention to workforce, building an infrastructure for primary care, or a focus on care coordination. Each of these activities is critical and contributes to success of the others. By the same token, we cannot build a reformed health care system on an endangered primary care enterprise. We must invest now. Primary care is too important to fail.
David S. Meyers, MD
Carolyn M. Clancy, MD
Agency for Healthcare Research and Quality
Rockville, MD 20850
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Edward J. Volpintesta
February 19, 2009
Save primary care by training new types of primary care doctors
The authors' suggestions for having local community support in providing primary care offices with infrastructure support including social workers, quality improvement officers, social workers, and health educators have merit (1).
The core of the problem however, is not the coordinating functions themselves that primary care doctors have to do but the sheer number of them. The toll they take on their composure and job satisfaction robs them of fulfilling the humane doctor-patient relationship that both they and their patients desire.
Perhaps the logical first step would be to look for ways to produce more primary care doctors in less time. This would increase their numbers. Having more of them in the workforce would mean less administrative and coordination work for each. This could be achieved by placing students into general practice programs early on in their education. For instance why not reduce college to two years and med school to three? Those who want general practice could enter their residencies immediately. Those wanting specialty or research careers could stay on in college or in medical school for more intensive basic science courses. By knocking off three years from training general practitioners could be turned out in eight years instead of eleven.
When I think back on the hours spent on biochemistry, calculus, organic chemistry, physical chemistry, and biology of invertebrates and vertebrates and how little a part they have played, and continue to play in my professional life as a general practitioner, I question the value of the so called "pre-med" programs that many students undergo.
I recall several good students who would have made excellent general practitioners but who gave up on medical school because of low grades in the sciences. Some went on to become chiropractors, optometrists, and dentists; others became teachers and PhD's. Such was the reality of pre-med education when I went through the process forty years ago. After perusing a current MCAT preparation book it seems the process is more biased towards basic science than ever.
Opponents of a shortened approach to producing general practitioners will say that shortening the exposure to basic science would not provide a sound scientific basis needed for residency. I disagree. Is all that basic science really necessary for general practice? And haven't our medical schools really been preparing students for careers in specialties, not general practice? Doesn't the lack of primary care doctors belie educators' concerns and promises to produce more of them?
Medical education is geared to training medical students for careers in research and specialty medicine. The blessings from this approach are great. But doing it at the expense of not providing alternative pathways to produce general practitioners is counterproductive. The result is an unbalanced health care system.
It is overly optimistic to think that increasing the infrastructure personnel alone will solve the primary care problem. Fairer reimbursement is long overdue of course, but attention must also be given as to how best improve the enjoyment and satisfaction that a career in primary care offers doctors.
If medical educators believe that primary care is too important to fail, then shortening the training period for primary care doctors by making it more suitable for what their jobs demand of them is one important way of saving it.
1. David S. Meyers and Carolyn M. Clancy Primary Care: Too Important to Fail Ann Intern Med 2009; 150: 272-273
Marcus M. Reidenberg
Weill Cornell Medical College
February 24, 2009
Student Debt and Primary Care
The editorial by Meyers and Clancy suggested several ways to support primary care but did not discuss a need to support student debt repayment. The AAMC states the average student debt of graduates of public medical schools is $142,140 and that of private school graduate is $173,304. An overall average debt of about $159,000 requires repayment starting after residency of $2600 per month or $31,000 of after tax income per year on a 10 year repayment plan. Bodenheim, in an earlier Annals paper, gave average primary care income as $156,000 annually and Physicianssearch.com stated average primary care pre-tax income at $123,000 in the first year of practice. Repaying $31,000 after tax from $123,000 pretax probably enters into decisions of career choice for some medical school graduates. Consideration of an enhanced student loan repayment program should be part of any comprehensive program to support primary care.
Money plus paradigm shift needed to make primay care attractive
As Dr. Marcus M. Reidenberg mentioned in his Feb. 24 rapid response "Student debt and primary care", helping students to repay their educational loans is an important step in making primary care more attractive, especially in view of their disproportionately lower income compared to specialty practices being on average about one-half.
Many primary care doctors make considerably less than the $123,000 to $156,000 he mentioned. For most doctors making those amounts is inconsistent with primary care because it requires seeing too many patients. To generate those amounts would leave them with little time and energy to give their patients what they expect. Worse, there would be almost none left for their personal lives or participating in medical affairs.
Even if one's school debt were completely forgiven, the work environment would still contain the same amount of administrative drudgery imposed by health insurers as well as the ever-increasing volume of coordination activities.
Money alone will not attract more doctors to pirmary care because any added income will quickly go to pay for more ancillary help. This is sure to happen when the so-called medical home is put into place.
The point is that a new paradigm is needed for primary care. One that takes into account the limits of doctors qnd patients' desires for humane treatment.
If primary care doctors were paid on a fee -for -service basis on usual and customary charges as they were under indemnity insurance , freed from the necessity of getting authorization for tests and consultations, they would derive much more satisfaction from their work. The money saved by not having to pay for personnel to deal with paperwork imposed by insurers alone would save a primary care doctor about $20,000 a year.
1. Reidenberg, M. Letter. Ibid Pg.272-3.
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