Commentary
A Better Way
By George Shoephoerster, M.D.
We know what's needed in primary care. Now, let's fund it.
It’s 6:15 p.m. and I’m trying to remember why I got into primary care medicine in the first place. I’m heading into the next examination room to see the last patient on my schedule. As is often the case, I am running more than an hour behind. I had hoped to meet my wife for a sandwich before her orchestra practice at 7 p.m. But that hope is quickly dashed as I realize who this last patient is: Mr. Heartsinque. I know it will be impossible to complete this visit in just 15 minutes. Mr. Heartsinque has poorly controlled diabetes, hyperlipidemia, and hypertension complicated by a depression that was made worse by his recent divorce. Among other things, he struggles to keep track of his medications. Most visits find me trying to review his complicated treatment regimen while he is discussing his divorce and his relationship with his children. Today, I’m feeling like a failure because the quality-of-care report card that I recently received from his health plan reminded me that Mr. Heartsinque is an outlier because of his elevated glycosolated hemoglobin.
Today’s visit will be even more difficult because at his last one, we did a PSA, which came back elevated. So now, in addition to talking about his other problems, I will need to explain the statistical implications of the test result and then arrange a referral for biopsy, if I convince him that the potential benefit will be worth the pain. Meanwhile, I know that Mr. Heartsinque will bring up some new symptom.
As I enter the exam room, I try to remind myself of the satisfaction that I still feel seeing patients and of the gratitude that the Mr. Heartsinques of my practice occasionally will express. But the days just don’t seem long enough for me to do all of the things that everyone is asking me to do for my patients, such as getting prior authorizations for imaging, adjusting medications because an insurer’s formulary changed, making referrals, completing work and school excuse forms, and contending with a new electronic medical record system that after 15 months still requires me to spend three to four extra hours each day documenting the care I’m providing for my patient panel. I wonder, am I just getting too old to keep doing this? Or is it that I—like other primary care physicians—am stuck in an approach to patient care that no longer works because it is not much different from that used in the 19th century? If it weren’t for the joy that I get from seeing the patients I have known for years, I might have quit long ago. But I didn’t, and today, I’m hanging on because I believe that we just might be on to a better way of doing what we do.
A New Approach to Care
Early in 2008, health care reform legislation was introduced in both the Minnesota House and Senate that includes a description of and a mechanism to pay for an approach to care called “medical home.” A medical home is not an actual structure, such as a house or a building. Rather, it is shorthand for the type of care I want to be able to offer patients such as Mr. Heartsinque—care that is patient-centered, physician-guided, cost-efficient, and ongoing. It’s an approach that sharply contrasts with our current episodic, illness-oriented, complaint-based way of treating patients.
The medical home model is based on what we have learned about providing effective primary care during the last 20 years. For example, the popularity of retail clinics has taught us how to make ourselves more available to patients. We’ve learned from our patients themselves about the importance of continuity—when they need care, they want to be able to see a doctor who knows them and not whoever happens to be available or whoever their insurance company tells them to see. We know that we need to be comprehensive, to take a holistic approach to eliciting and discerning a patient’s health care needs and preferences, to track their progress over time, and to be held accountable for using processes that effectively assist patients in reducing their cholesterol or bringing their blood glucose reading into line. We’ve become schooled in the importance of communicating with care team members and providers in other settings including hospitals and retail clinics in order to effectively coordinate care.1 We’ve learned that caring in context requires having an accurate understanding of who our patients are, how they live, and what’s important to them. Finally, the quality movement has shown us the importance of continuous improvement.
But by only rewarding us for patient visits and procedures, our current fee-for-service reimbursement system has undermined many of these elements of good primary care. In order to get back to the kind of practice that attracted many of us to medicine in the first place, payment reform needs to happen.
Goroll has proposed one promising compensation model.2 He describes a system in which payment for comprehensive patient care replaces fee-for-service. Payers would not reimburse providers for the total cost of care, as was done in the capitated systems of the health maintenance organization days, but instead would invest in primary care practices by supporting patient care over time. Payments would be risk-adjusted so that practices would not be tempted to move more difficult patients down the road to the next clinic. Pay-for-performance bonuses would promote quality care. And payers would still be responsible for hospital, specialty, and ancillary services so that practices wouldn’t become insurers, as they did under capitation.
More than two-thirds of the payment to the medical practice would support the teams and systems essential to improving care. Those funds might be used for the salaries of a nurse practitioner, a nutritionist, a social worker, and/or a case coordinator/data manager, as well as for information technology. The remaining one-third of the payment would be for physicians’ salaries, which would be commensurate with responsibility assumed and value created. Rather than being told to see more patients, primary care physicians would be encouraged to build long-term relationships with their patients. I think such a system could ensure a steady supply of primary care providers in the future.
How would this method of funding primary care affect health care costs? Studies have shown that when personal physicians work in the context of a well-supported medical home, there are savings through a reduction in the inappropriate use of the emergency room, the hospital, and high-tech imaging. The CEO of my local health system pointed out that the greatest line-item expense on the hospital ledger is staff. Decreased emergency room visits and hospital admissions would likely result in the need for fewer staff, which also just might help to solve the impending nursing shortage.
Savings would also come from more effective utilization of other physician specialists. I would argue the medical home model will create savings, not by limiting access to physicians (the old gate-keeper model), but rather by eliminating barriers to essential care. By implementing a limited medical home model approach several years ago that encouraged every employee to have a primary care physician, Mayo Clinic found that its specialists were much more satisfied because their waiting rooms once again were filled with patients who actually required their services. As I once was informed, “The world’s expert on sarcoidosis once again has a waiting room filled with patients with sarcoidosis!”
The Doctor as Team Leader
Adopting the medical home model will involve more than just changing the way health care is paid for. It also will require changing the role of the primary care physician. We will need to learn how to build and lead teams that include patients, other physician specialists, nurses, therapists, and other service providers in our communities. In order to do that, we physicians will need to give up some of our autonomy and independence in the interest of doing what’s best for the patient. Today, primary care practices are really structured as “dual organizations.” There’s a “federation of physicians who emphasize autonomy and independence and an organization of support staff whose primary purpose is to process patients for the physicians to see efficiently.”3 That system worked when most patients were seeking acute care and the physician was the primary service provider. However, as more patients deal with complex, chronic conditions, we will need to determine how to best expand the roles of all members of the health care team in order to meet those patients’ medical and emotional needs in the most beneficial, cost-efficient way.
The goal of the medical home approach is for physicians to provide care that is in line with the patient’s values and preferences. And when we do that effectively, research has clearly shown that there will be better outcomes for the patient, lower costs for the health care system, and greater satisfaction for the provider and the patient.
As I had predicted, even before his electronic medical record comes up on the screen, Mr. Heartsinque is describing an episode of right-sided chest pain. So now where do I go, I ask myself. Atypical chest pain, poorly controlled diabetes, poorly controlled hypertension, possible prostate cancer? So much for dinner with my wife.
I think about how we could do better for patients such as Mr. Heartsinque. If payers were supporting the necessary structures for longitudinal primary care, his chronic diseases would likely be better controlled thanks to group visits, education by a nurse, or counseling by a psychologist. And I’d have 30 minutes, rather than 15, to sort out his health care issues, some of which could then be more appropriately (and probably more effectively) addressed by others in his medical home. I see this way of practicing medicine on the horizon. I just hope it gets here soon. MM
George Schoephoerster is a family physician in St. Cloud and president-elect of the Minnesota Medical Association.
References
1. Presentation by David Hutchinson, M.D., president of the Minnesota Academy of Family Physicians (MAFP), at the MAFP Spring Refresher, April 2008.
2. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med. 2007;22(3):410-5.
3. Crabtree BF, McDaniel Jr RR, Nutting PA, Lanham HJ, Looney A, Miller WL. Closing the physician-staff divide: a step toward creating the medical home. Fam Pract Manag. 2008;15(4):20-4.