Ernest Brown, MD, prides himself on staying on top of his patients’ care, whether he treats them personally at his Washington, D.C. office—or they see a specialist or an emergency room physician.
When they are admitted to hospitals, he says “I go with them and I advocate for them. I know the emergency room doctors. I make sure their care is thorough. I follow them until they are out of the hospital.”
Brown has time to play a role that is increasingly out of reach for primary care physicians because of the creative way he has structured his practice. He only does house calls and doesn’t take insurance, which enables him to avoid the time-consuming paperwork required.
“I have that luxury. I don’t have 30 patients to see in a day—and I’m mobile,” he says. He also has the freedom to see patients who are unable to pay.
Related: Becoming a PCMH
Brown’s approach isn’t for every physician, but it reflects the frustrations that many doctors feel at a time when delivering better continuity of care seems increasingly out of reach. “When you look at a clinic, you are talking about volume vs. value,” Brown says. “You’re talking about 10 to 15 minutes with the patient, whenever they happen to come in.”
The primary care quarterback
Few would disagree that when primary care doctors quarterback a patient’s care in a comprehensive way, quality improves and costs decline. A January 2014 study on patient-centered medical homes—where the family physician serves as the hub of the patient’s care—found that the approach decreased the cost of care, reduced the use of unnecessary or avoidable services, helped in controlling health indictors in the patient population such as blood pressure, improved access to care and boosted patient satisfaction. The study was done by the Patient Centered Primary Care Collaborative, a coalition of more than 1,200 patient centered medical homes.
But despite efforts by the federal government and private insurers to include continuity of care into evolving models of payment and care, the barriers to achieving it are mounting, say some physicians.
“There is no continuity of medical care,” says Thomas E. Bat, MD, a physician with 30 years’ experience who practices at North Atlanta Primary Care in Georgia, a patient-centered medical home with 23 physicians. “When a person leaves the sphere of family medicine or primary care and moves to the specialty arena for some chronic disease management issue or the emergency arena for acute care, each of these entities has their own team-based approach. The teams don’t communicate at all.”
The current system makes continuity of care so hard to achieve, says Bat, “there are days when I look at it that I feel like Don Quixote.”
Why is continuity of care slipping out of reach? In theory, primary care physicians’ work should be getting easier.
The Affordable Care Act brought more consistent access to care to millions of low-income Americans by expanding access to Medicaid. In the first half of 2014, the number of people covered by Medicaid grew by more than six million, with 71% gaining eligibility because of the ACA, according to an October 2014 estimate by the Heritage Foundation.
Meanwhile, the number of people receiving private insurance coverage increased by a little under 2.5 million in that same period, once the number of people who signed up under the ACA and the number of people who lost employer-sponsored coverage were factored in.