Reinventing primary care focus of research series

The U.S. primary care system is in such a bad state that not only does it need to be revived, it also needs to be reinvented, according to researchers.

Health Affairs in May featured a series of studies focused on the primary care crisis. Although the system is understaffed and under stress, it can be repaired by focusing on care coordination, medical homes and other innovations, researchers wrote.

The journal articles show that the nation's primary care system "is horribly broken -- the victim of underinvestment, misaligned incentives and malign neglect," said Susan Dentzer, Health Affairs' editor in chief.

In the U.S., primary care responsibilities belong to several physician groups, including family physicians, general internists, geriatricians and general pediatricians. But all these doctors are facing increasingly impractical and burdensome workdays, one study found.

"Many primary care physicians are overwhelmed by crammed schedules, inefficient work environments, and unrewarding administrative tasks, and the quality of physician-patient interactions in primary care has been declining," wrote Thomas Bodenheimer, MD, MPH, and Hoangmai H. Pham, MD, in one article. Dr. Bodenheimer is an adjunct professor of family and community medicine and co-director of the Center for Excellence in Primary Care at the University of California, San Francisco. Dr. Pham is a senior health researcher at the Center for Studying Health System Change in Washington, D.C.

Moreover, providing primary care is becoming increasingly complex, the authors said. For example, family physicians address an average of three patient problems for every visit, with the average number of problems increasing to 3.8 for elderly patients and 4.6 for patients with diabetes.

On top of that, primary care physicians are paid far less for their services than are specialists, wrote Drs. Bodenheimer and Pham, and are generally not paid at all for care coordination and other services performed outside of the patient visit.

"These realities have led to major discussions about the need for significant physician payment reform," the researchers said.

Enter the medical home

Several studies in the primary care Health Affairs issue examined the concept of using the patient-centered medical home to address the crisis.

One analysis examined seven medical home programs that have proven successful. The investigation found four common features: the use of dedicated care managers; expanded access to physicians and other health professionals; data-driven analytic tools; and the use of incentives.

One of the programs analyzed -- Seattle-based Group Health Cooperative -- reported that for every dollar it invested in the medical home, it recouped $1.50. Due to the successes of the initial medical home that it created, Group Health had spread the concept to all 26 of its Pacific Northwest medical centers by the end of January.

"A medical home is like an old-fashioned family doctor who really knows you as a person," said Robert J. Reid, MD, PhD, Group Health's associate medical director for preventive care. "The fresh twist is that the doctor leads a team of professionals."

The two-year evaluation of Group Health's medical home model found that patients had 29% fewer emergency department visits and 6% fewer hospitalizations, resulting in a net savings of $10 per patient per month.

"Nationally, the patient-centered medical home is emerging as a key way to improve health care and control costs," Dr. Reid said.

Staffing issues persist

Researchers expressed doubts as to whether there will be enough physicians to care for the growing elderly population.

By 2030, the older adult population will swell to more than 70 million and account for one in every five Americans, wrote researchers from the Johns Hopkins Bloomberg School of Public Health in Baltimore, the Indiana University School of Medicine in Indianapolis, Mount Sinai School of Medicine in New York, and the Health Policy Center at the Urban Institute in Washington, D.C. But in recent years, the number of physicians entering American geriatric medicine fellowship positions has remained essentially unchanged -- 290 in 2003 and 293 in 2008, they noted.

"We clearly cannot count on having enough geriatricians to care for all older adults with multiple conditions," the authors wrote.

As a result of the demographic pressures, the concept of training physicians in the basics of geriatric chronic care has received increasing attention recently, they said. For example, essential geriatrics competencies recently have been identified for medical students and residents in internal, family and emergency medicine.

J. Fred Ralston, MD, president of the American College of Physicians, said the series of research on primary care is timely.

"It comes at a critical juncture, because we're dealing with many sagas right now, including the [Medicare] sustainable growth rate and reactions to the health reform legislation," Dr. Ralston said. "The key elements are the absolute crisis we're in, and the fact that there is literally no way to make our system more effective without improving primary care."

Bill Leinweber, executive vice president and CEO of the American Academy of Physician Assistants, agreed.

"We believe very strongly that primary care is currently in a very precarious situation," Leinweber said. "Clearly, the medical home is a key issue. But who's going to run them? There simply aren't adequate work force resources right now."

Without intervention, the U.S. will face a shortage of 46,000 primary care physicians by the year 2025, according to the Assn. of American Medical Colleges.

Physician assistants could help bolster the work force, but only if the pay gap between primary care physicians and specialists is also addressed, according to researchers from Duke University Medical Center and the University of North Texas Health Sciences Center.