David Margolius, MD; Thomas Bodenheimer, MD
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1112.
Requests for Single Reprints: David Margolius, MD, San Francisco General Hospital, 1001 Potrero Avenue, Building 80-83, San Francisco, CA 94110; e-mail, Margolius@gmail.com.
Current Author Addresses: Dr. Margolius: San Francisco General Hospital, 1001 Potrero Avenue, Building 80-83, San Francisco, CA 94110.
Dr. Bodenheimer: San Francisco General Hospital, 995 Potrero Avenue, Building 80, Ward 83, San Francisco, CA 94110.
Margolius D., Bodenheimer T.; Redesigning After-Hours Primary Care. Ann Intern Med. 2011;155:131-132. doi: 10.7326/0003-4819-155-2-201107190-00011
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Published: Ann Intern Med. 2011;155(2):131-132.
The article in this issue by Giesen and colleagues (1) on after-hours care in the Netherlands could not be more timely. Rising health care costs, particularly for Medicare and Medicaid, are devastating the U.S. budget. After-hours primary care, by reducing avoidable and expensive emergency department (ED) visits, could become a promising cost-containment strategy.
The Netherlands has implemented a system of after-hours care in which cooperatives, encompassing 40 to 250 primary care physicians (PCPs), make available telephone triage nurses with physician backup to care for patients during evenings and weekends. Nurses, responding to urgent patient requests, follow triage protocols and offer advice ranging from self-care to ED referral. Physicians supervise triage nurses and make urgent home visits when necessary. The PCPs work an average of 4 hours per week in this system, which provides after-hours care for more than 90% of the Dutch population.
Imperial College London
July 29, 2011
After-hours primary care services in England's National Health Service
Many of the innovations recommended by Margolius and Bodenheimer for after-hours primary care in the US health system are already present in England's National Health Service (NHS). All residents of England have access to free after-hours NHS primary care services, either provided by their own primary care physician or by their local primary care trust (the organization responsible for funding primary care services). After-hours primary care in England is defined as that occurring outside the hours of 8am to 6.30pm Monday to Friday, in contrast to some other countries, where primary care physicians may offer narrower access to routine services.
Where primary care physicians provide after-hours services themselves, this is usually through a cooperative system. In areas where primary care physicians do not provide after-hours care, this is then usually provided by a commercial provider and is funded by the local primary care trust. In addition to these primary care based services, residents of England also have access to a 24 hour telephone advice line (NHS Direct) that has been available nationwide since 2000. Other recent innovations in emergency and out of hours care in England have seen the introduction of 'urgent care centers' and 'minor injury units' staffed by primary care physicians and nurses; and the employment of primary care physicians in emergency departments to deal with patients who present with problems that do not need to be managed by specialist emergency physicians.
Despite the wide availability of primary care services and a readily accessible 24 hour helpline, attendances at emergency departments, urgent care centers, and minor injury units in England continue to rise (from 15.3 million in 2003-4 to 20.7 million in 2010-11, an increase of 35%). The explanations for this continued demand for emergency care in a health system with good primary care, both in routine hours and after-hours, are complex but seem to be linked to socio-cultural reasons, such as the desire of patients to be seen when it is convenient for them. The lesson from England for the USA and other countries with more fragmented and less widely available after-hours primary care services is therefore that a health system can strive hard to improve access to after-hours primary care but this by itself may not be enough to curtail the demands placed on emergency departments.
1. Margolius D, Bodenheimer T. Redesigning After-Hours Primary Care. Ann Intern Med 2011;155:131-132.
2. Giesen P, Smits M, Huibers L, Grol R, Wensing M. Quality of After- Hours Primary Care in the Netherlands: A Narrative Review. Ann Intern Med 2011:155:108-113.
3. NHS Direct. http://www.nhsdirect.nhs.uk/. Last accessed 29 July 2011.
4. Department of Health. Accident & Emergency Attendances. http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/AccidentandEmergency/DH_077485. Last accessed 29 July 2011.
5. Majeed A. Inversion of emergency pyramid. "I wanted a thorough checkup". BMJ 2003;326:553.
I am a general practitioner in the practice of Dr Curran & Partners (www.claphamhealth.nhs.uk). After-hours services to patients in my practice are provided by a general practice cooperative, SELDOC (http://www.seldoc.co.uk/). I have received funds for research from the NHS to evaluate new models of after-hours primary care in London.
Michael E. Miller
Boston University Affiliated Physicians
August 2, 2011
Need Value Driven Health Care System
Margolius and Bodenheimer's editorial response to Giesen and colleagues review of After Hours Primary Care In The Netherlands (Annals, 19 July 2011), suggesting that the US consider adopting the successful Dutch model, fails to mention several essential differences between the two countries health care systems that would make that process difficult.
The Netherlands and most of Western Europe have invested in more fully developed primary care systems than the US and seem to more highly "value" primary care physicians; there is a notably smaller "salary gap" between specialists and primary care providers. Specialty societies in the US are adamant about not reducing their member's income to enhance that of the primary care sector. Health insurance is mandatory in the Netherlands, enhancing access and limiting out of pocket expense. Taking time off work to see a physician is not as anxiety provoking. Here, at least in Boston, extending office hours seems to only "time shift" regular patient visits from weekdays to evenings and weekends. Recently, "patient directed" (aka higher deductable and copayment) insurance plans have led to more phone calls during off hours to manage patient problems without an office visit, and its fee.
Primary care providers are disproportionally burdened in the US. Too many hours and administrative hassles with less compensation, and, unmistakably feeling the increasingly salary- threatening schizophrenic demand to boost productivity while being tasked with constraining health care system costs makes for a not very attractive primary care career choice. The creeping "conditional" nature of the mechanism for enhancing one's salary is most marked in primary care. Surgeons and specialty physicians don't conditionally generate additional income by not operating or performing fewer procedures. Asking primary care organizations to now assume a disproportionally large share of financial risk for the provision of care to a population of patients only worsens the environment. Medical student's internship choices show that idealism and altruism, but often accompanied by substantial debt, will significantly limit those same choices, more often away from primary care.
Accountable care organizations will certainly promote less emergency room utilization to reduce cost/financial risk, but the elephant in the ACO boardroom will be the one who gains control of the ACO. It's not only hospital administration versus physicians; there could be "blood on the floor" as specialists and primary care docs vie for the power of the purse. Past experience unfortunately holds out scant hope for increasing the value in the ACO of primary care cognitive services as opposed to the procedure oriented services of the specialties.
My longitudinal view of thirty years in primary care; from friendly competition, to managed competition, to oppressive managed care HMO gatekeepers, to expensive PPO's/EPO's, to urgent large scale institutional consolidation, to cutthroat competition, to high deductible cost-shifting, patient-directed plans, and currently perhaps to ACO's, parallels the clear decline in the practice environment, prestige, relative compensation, and numbers of newly minted primary care physicians.
Until our country's health care system radically evolves to a value driven (primary care driven) institution, covering all Americans, we can only admire how far ahead of us, at least in certain system-wise aspects, are the Dutch and the European primary care structures; all the while, our patients experience ever longer waits and incur ever greater expense in our state of the art emergency rooms.
Michael E. Miller, M.D. Member ACP, #058249 Boston University Affiliated Physicians 780 Boylston Street Boston, Ma. 02199 Michael.Miller@bmc.org
September 9, 2011
To the Editors:
We thank Drs. Majeed and Miller for their letters. We have no disagreements with their comments, which underline the challenges facing primary care. Emergency departments have a great access advantage over traditional primary care practices - patients can go at 6 PM or 1 AM and will be seen the same day. However, the benefits of continuity of care - improved preventive and chronic care, higher patient satisfaction, and lower costs  - can only be achieved by empaneling patients to a primary care home and ensuring prompt access to that medical home. Shining examples exist of US primary care practices that are providing both prompt access and continuity . It can be done.
David Margolius MD Thomas Bodenheimer MD
1. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 2005;3:159-166.
2. Bodenheimer T. Lessons from the trenches - a high-functioning primary care clinic. N Engl J Med 2011;365:5-8.
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