With the stunning Supreme Court 5-4 majority decision to uphold the Patient Protection and Affordable Care Act (ACA), there’s a Roberts’ Rules of (Health Reform) Order that calls for liberating primary care beyond the doctors’ office. That’s because a strategic underpinning of the ACA is akin to President Herbert Hoover’s proverbial “chicken in every pot:” for President Obama, the pronouncement is something like, “a medical home for every American.”
But insurance for all doesn’t equate to access: because 32-some million U.S. health citizens buy into health insurance plans doesn’t guarantee every one of them access to a doctor. There’s a primary care shortage in much of America — the American Academy of Family Physicians estimates that the number of primary care doctors fell 52% since 1997. In raw number terms, 1 in 5 people in the U.S. lack a primary care home, with a shortage of 90,000 projected for 2020 — 8 years from today. That’s not enough time to train that number of physicians, even with the incentives to attract new primary care providers (PCPs) included in the ACA.
The solution? Liberate primary care in several ways, as I detailed in my paper, Primary Care, Everywhere, commissioned by the California HealthCare Foundation in November 2011.
Why the hub-bub around primary care? Because the world over, those nations that spend most cost-effectively on health care are those with the strongest primary care backbones. By ensuring that each health citizen has a patient-centered medical home, a country can avoid duplication, inefficiency, and high-cost care driven by specialists and others used inappropriately for the wrong patient at the wrong time and place. The PCP, coupled with the electronic health record, can track and manage population health and drive better outcomes for people, while neither over-treating or under-treating. That’s the theory.
Without sufficient PCPs, the solution is team-based care, where the medical home can be the central locus of care but with delivery of that care accomplished by a team that works with the physician: nurses, nurse practitioners, physician assistants, nutritionists, diabetes educators, and others affiliated in that practice. But then in the larger community, there are many other hubs of primary care that complement the medical home: most notably, the pharmacy, the worksite clinic, retail health clinics, school-based clinics, Federally Qualified Health Centers (which can function as medical homes), fitness and rehab facilities, and the much-overlooked actual home of the patient.
A team-based approach breaks down siloes, and opens up the supply side of primary care beyond the PCP-focused model. Furthermore, the decentralized delivery of care brings that care closer to the patient in her community where she “lives, works, plays and prays,” as our Surgeon General Dr. Regina Benjamin says. This approach promotes access, cultural sensitivity, and can bolster patients’ adherence and consistency in self-care — critical for bending the cost curve and avoiding unnecessary admissions through the ER or to the doctor.
How this happens is through realigning incentives — payment, reimbursement, value-based benefit design — that promote the primary care home for every health citizen. In the short-run — and here, in medical education terms, a decade — we must embrace a team-based approach to primary care, underpinned by an electronic health record for each health citizen.
Health Populi’s Hot Points: The undersupply of PCPs requires team-based care: a shared responsibility on the clinical side for treating patients at the right place, right time, with the most appropriately skilled labor. PCPs, at a deficit, must be deployed to their highest and best use: that is, restructuring clinical work processes that ensure PCPs do what they’re trained to do, delegating lesser tasks to appropriately train clinical staff. Where deployed, team-based care has resulted in greater patient, physician and nurse satisfaction, better productivity, improved quality measures and outcomes, and improved bottom-lines.
Team-based care is the modus operandi for accountable care and value-based health plans. It means collaboration: within teams in practices, between teams across practices, and across health industry segments/stakeholders. The accountable care orientation, where payment rewards population health, will require organizations working together who have never before aligned: pharmacy chains with physician practices, worksite clinics liaising with PCPs, diabetes educators and nutritionists with school-based clinics, pharmaceutical and life science companies with patient advocates and caregivers, health plans with remote health monitoring/telehealth companies. This is the new primary care, everywhere.