Primary care needs to be overhauled: Here's how to do it

March 7, 2013

Primary care is the "beleaguered," "underappreciated stepchild" of U.S. healthcare that's on a "mission impossible" as currently organized, but three prominent thought leaders believe they've created the recipe to change that.

Primary care's problems stem from the way most primary care practices are organized, according to a recent study in Health Affairs. Specifically, today's primary care practices "attempt to meet the disparate needs of heterogenous patients with a 'one-size-fits-all' approach," the study says.

Primary care practices generally have no organizing principle beyond increasing the volume of services for which they can be reimbursed, according to study authors Michael Porter, MBA, PhD, a Harvard business professor; Erika Pabo, MD, MBA, a clinical fellow at Harvard Medical School; and Thomas Lee, MD, MSc, network president at Partners HealthCare in Boston.

Unless primary care is redefined and organized in a different way-one in which it can "deliver and demonstrate measured value"-the field will remain marginalized, according to the study.

"We believe that most healthcare organizations currently operate without an overall strategy for improving primary care," the authors write. "Consequently, the hard work of clinicians is dissipated because of a lack of clarity about what they are trying to accomplish, and for whom."

The key to redefining primary care lies in shifting it to what the authors call "value-based patient subgroup management." Fair enough, but what does that mean?

The authors list the following "five essential elements" of this management approach.

Basing primary care on patients' needs: This involves designing care delivery processes and outcome measures around a small number of subgroups of patients with similar needs and challenges. Then, these measures of outcomes and costs that are tailored to particular subgroups should replace current measures that focus on the volume of services physicians provide. Subgroups should be based on the type of care patients need, rather than discrete diseases such as diabetes or hypertension. Examples of subgroups include healthy adults and adults with multiple chronic conditions.

Integrating delivery models by subgroup: This is all about developing the teams that are focused on care delivery and improvement for each patient subgroup. Who is on the team? How do team members work together across the continuum of care? In what locations? Using what tools? "For most primary care practices, the development of effective teams that are true drivers of care integration would be the greatest departure from the status quo," the study says.

Measuring value for each patient subgroup: The first step is to identify multiple outcomes that matter to patients, which will differ by subgroup. For a subgroup involving chronic illnesses or complex conditions outcomes will be a combination of general measures like quality of life and timeliness of care, and specific measures for a particular disease. Another key portion of this is measuring total costs, including those outside of primary care, for each subgroup.

Aligning payment with value: The authors advocate time-based bundled payments, which are payments for a defined group of services for a specific patient subgroup during a specified period of time. "Clinicians have difficulty responding to the imperative to reduce spending in a fee-for-service system with anything besides arbitrary cuts and discontent," the authors write. "Bundled payments for the care of specific patient groups, in contrast, enable more thoughtful choices for primary care providers and reward improvement."

Integrating subgroup teams and specialty care: While healthy children and adults will have most of their health needs met through primary care, those with serious or complex conditions, for example, are likely to need additional specialty care. The mix of specialty and primary care will vary by subgroup, but the main idea is that providers of both types must function as members of a joint team, centered around meeting the needs of patients. That requires specialty and primary care providers to share protocols, define handoffs and build personal relationships, according to the study.

Although creating care coordination teams and dividing patients in subgroups may sound like a lot for the average primary care practice to handle, the authors stress that these changes aren't "radical." Several organizations-including Commonwealth Care Alliance, CareMore, Intermountain Healthcare, and the U.S. Department of Veterans Affairs-already have implemented some elements of the value-based model of primary care, according to the study.

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