Care Transformation Center Blog

The radical rethinking of primary care is underway

In November 2008, the New England Journal of Medicine convened a small roundtable to discuss “Redesigning Primary Care.”

    U.S. primary care is in crisis, the roundtable’s description reads. As a result … [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.

Nearly five years out—and dozens of reforms and pilots later—the primary care system’s condition may still be acute. But as managing editor for the Advisory Board's Daily Briefing, I've noticed a clear trend among health care policymakers and progressive leaders: after decades where primary care’s problems were largely ignored, they’re not letting this crisis go to waste.

Ongoing shortage forcing decisions

The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.

It’s a predicament that leads to shared suffering for patients (who face long wait times), primary care physicians (who are exiting the business), and the nation’s health system (which bears the burden of added, expensive interventions by specialists).

As readers of this blog know, the Affordable Care Act does include a number of provisions intended to strengthen primary care; for example, the law increases payment rates for PCPs in 2013 and 2014, launches new training programs, and includes a slew of delivery-reform pilots.

Altogether, experts expect that the law will increase the number of PCPs by about 3,000 over a decade—but that would still leave the nation more than 40,000 short by 2020, according to estimates from the Association of American Medical Colleges.

Broader push for innovative redesign

The gap in manpower is one reason why many other attempts to more radically transform primary care are underway, ranging from changes in how care is delivered to where patients are being seen.

Providers latch onto the patient-centered medical home model (PCMH): More than 45 years after its debut, the medical home concept—where a team of providers collaborate to deliver primary care—is finally taking hold.

Hundreds of hospitals, medical groups, and community clinics are piloting PCMHs, with a boost from payers and lawmakers. A 2012 study from the Commonwealth Fund found that about half the states have implemented PCMHs for their Medicaid populations.

Paramedics stop waiting for emergencies: Hospitals in several states are piloting a model where paramedics pay proactive house calls to frail and elderly patients, in order to perform basic tests and unusual interventions—everything from helping arrange for a wheelchair ramp to even baking cookies.

The new model (“We are kind of inventing this,” according to one community paramedic) is intended to keep patients out of the ED.

Pharmacy chains push into frontline services: Walgreens this month announced an unprecedented step to diagnose and treat patients with chronic conditions. And as covered recently, the retail chain also has redesigned many stores to bring pharmacists out from behind the counter to instead sit at open desks and offer medication consults.

Meanwhile, Rite-Aid has announced that it’s expanding an in-store consult service, where customers can pay $45 to have a 10-minute video chat with a physician.

Insurers moving into care delivery: After mostly withdrawing from integrated delivery systems in the 1990s, payers have purchased a number of clinics and medical practices in recent years, as they experiment with tactics to hold down care costs and better integrate wellness.

In one of the most striking deals, United Health in February announced that it was partnering with The Villages in Florida—perhaps the nation’s largest retirement community, with nearly 100,000 residents—to launch a network of primary care clinics dotted throughout the three-county community.

“When our system is finished, [health] care will be just a golf-cart-ride away for all Villagers,” predicts The Villages CEO Gary Morse.

A transformational moment

This focus on rethinking primary care is a huge opportunity. But are providers poised to take advantage of it—or will players like Walmart and the United Health swoop in with their disruptive innovations?

“This new vision for primary care requires several fundamental power shifts,” Iora Health’s Rushika Fernandopulle wrote in Health Affairs last summer, touting his own model to redesign primary care clinics.

 And “no one likes giving [power] up voluntarily … [but] it is ultimately in the medical industry’s interest to adapt and innovate with consumer trends, or risk becoming obsolete, as many travel agents, book stores, and stock brokers have learned over the past several years,” he concludes.

Learn More

We recently hosted a webconference exploring the primary care clinic of the future. Listen to the recording or read our blog post for the three top takeaways.

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