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Grumbach & Grundy: Multistakeholder Movement Needed to Renew and Reform Primary Care

As the implementation of health care reform unfolds, urgent action is needed to shore up the nation’s crumbling foundation of primary care.

[IMGCAP(1)]It is difficult enough for many Americans today to find a primary care doctor; we can only imagine how tough it will be as millions more Americans appropriately gain access to the system in the years ahead. And there are plenty of signs that the current primary care crisis is only getting worse. For example, half as many U.S. medical school graduates are entering the primary care fields of family medicine and general adult medicine today, compared with 15 years ago.

Primary care is the foundation of high-performing health systems. A primary care physician, working alongside nurses and other team members, serves as a patient’s trusted personal physician who delivers patient-centered, “whole person” care. Research clearly shows that primary care is good both for people’s health and their pocketbooks, preventing disease, assisting patients to navigate a complex health system, helping patients to manage chronic conditions such as asthma to avert asthmatic attacks and reducing trips to the emergency room — and the associated high costs of hospital care.

Yet the nation’s inadequate investment in primary care is producing an epidemic of “medical homelessness” — patients unable to find a primary care medical home. From 2006 to 2008, for example, the number of Medicare beneficiaries experiencing difficulties finding a primary care physician increased by 17 percent. This urgent problem is spurring concerted action among a broad coalition of stakeholders, as we noted in an article we wrote along with Sen. Kay Hagan (D-N.C.) and AARP President Jennie Chin Hansen in the current issue of the health policy journal Health Affairs.

A leading force among these stakeholders is the Patient-Centered Primary Care Collaborative, consisting of some 700 organizations including large employers such as IBM, Dow Chemical, Whirlpool, consumer groups such as AARP, unions, primary care clinician organizations, health plans and others. Its aim is not just to prop up primary care, but to transform it to lead a durable 21st-century health care system.

For purchasers and health plans, that means paying differently. This includes using innovative payment models to support the time physicians spend communicating with patients by e-mail or phone, or developing an integrated care plan with the patient’s home care team or physical therapist; supporting nonphysician personnel to educate patients in self-management of their diabetes or arthritis; and modernizing practices through adoption and meaningful use of electronic medical records and other health information technology.

For primary care physicians, a new compact for primary care means becoming more patient-centered and accountable. This includes enhancing accessibility through expanded office hours, convenient same-day appointment systems and health information technology systems allowing patients to access their lab results online and e-mail their physician; working in teams with other health professionals such as nurses and pharmacists; and explicitly monitoring performance on key quality and patient-safety metrics.

In communities across the nation, purchasers, payers and primary care clinicians are building these advanced models of primary care. In the Hudson Valley and Adirondack regions of New York, the major private health plans and state Medicaid program are collaborating on a primary care reform initiative involving 700 primary care clinicians, supporting facilitation of health information technology implementation and care coordination payments. Similar multistakeholder initiatives are under way in Ohio, Colorado, Vermont and elsewhere.

Community Care of North Carolina invested in team-based primary care for Medicaid beneficiaries, improving quality while saving the state’s Medicaid program $400 million per year. Integrated health systems, such as Group Health Cooperative of Puget Sound and Geisinger, are also rapidly moving forward on institutionalizing redesigned models of primary care based on promising quality and cost outcomes from recent pilot programs.

The recently enacted Patient Protection and Affordable Care Act does provide some relief, including increases in Medicare and Medicaid fees for primary care, medical home innovation pilot programs, increased funding for National Health Services Corps primary care scholarships and loan repayment, incentives for recruiting students into rural medicine, and a primary care extension program to support practice improvement.

The unprecedented coalescing of diverse stakeholders around a forward-looking vision of revitalized primary care sends a powerful message that primary care cannot be a secondary consideration in the effort to achieve affordable, effective and equitable health care for the American people. Actualizing this vision will require sustained support for the role of primary care in a reformed health system.

Kevin Grumbach is a professor and chairman of the Department of Family and Community Medicine at University of California, San Francisco. Paul Grundy is global director of health care transformations at IBM in Somers, N.Y. He is president of the Patient-Centered Primary Care Collaborative.

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