Is The Primary Health Care
Crisis in America Solvable?
David Mechanic, Ph.D.
Institute for Health,
Health Health Care Policy
and Aging Research
Rutgers the State University of New Jersey
Rutgers,
June 28, 2010
Presented at the 2010 Annual Meeting of
AcademyHealth, Boston, MA
Primary Care is a Set of Functions Performed in
Varying Ways in Different Health Systems
• Easy accessibility and continuity
• First contact medical care
• Treatment of acute complaints
• Preventive care
• Monitoring and patient referral when needed
• Coordinating care across needed services
• Chronic disease management
• Patient education and support
__
__
__
__
__
__
__
__
F
Few
PC practices
ti
iin th
the U
U.S.
S approximate
i t
the desired models or QOC goals
__
Primary Care in the U.S. Provided by
a Variety
V i t off Clinicians
Cli i i
and
d iin M
Multiple
lti l S
Settings
tti
# of Clinicians/
Services/Facilities
Primary Care Physicians (35% of active MDs)
Family Practice/General Practice
General Internal Medicine
General Pediatrics
Data
Year
240,416
98,328
92,917
49,171
2008
Nurse Practitioners in Primary Care
92,000
2004
Physician Assistants in Primary Care
22 000
22,000
2004
HRSA Community Health Centers
Retail Clinics
Emergency Departments
Primary care provided by specialty physicians
8,170 (PCPs)
5,137 (NPs, PA, CNMs)
9 807 (Nurses)
9,807
approximately 1,000 clinics
2008
2009
approximately 4,600
434 million encounters
2002-2004
Sources: Robert Graham Center; Health Resources and Services Administration;
Science Daily 5/25/09; Valderas et al. Annals of Family Medicine 7(2):104-111, 2009;
Kellermann, NEJM, 355(13): 1300-1303, 2006.
Challenges
g to the Future of Primary
y Care
• Lack of a strong medical school primary care
teaching environment
• R
Relatively
l ti l llow reimbursement
i b
t–
recruitment increasingly difficult
• Lack off concordance between practice size and
organization and use of cost-effective practice tools
• Increasing time pressures making it difficult to meet
professional and patient expectations while meeting
target incomes
• Relatively low prestige among specialties
• Need for a more realistic business model
Effective Tools for Effective Primary Care
Require Scale of Organization Typically Lacking
• Electronic
ec o c Health
ea Records
eco ds fully
u y functional
u c o a
• Better use of evidence for decision-making
• Organized teamwork and collaboration
((NPs, PAs, etc.))
• Established coordination processes
• Improved clinical measures with continuing
feedback
• Patient registries and disease management
• Resources for meaningful patient involvement
in their care and patient education
Most Primary Care Physicians Continue in
Solo Practice, Partnerships and Small Practices
2005-06
% of Office
Based Primary
C
Care
Ph
Physicians
i i
Hing and Burt, Vital and Health Statistics, Series 13, No. 166,
Table 2
Slow Adoption of Electronic Health Records,
Particularly in Smaller Practices
Primary
P
i
C
Care
Other
Practice Size
# of physicians
1-3
4-5
6 10
6-10
11-50
>50
50
2007 – 2008
Fully Functional Basic
System
System
6
15
4
11
2
3
6
8
17
Neither
80
86
7
11
17
22
33
Source: DesRoches et al. NEJM, 359(1): 50-60, 2008
91
86
77
71
50
Percentage of Office-Based Physicians Using
Electronic Medical Records/Electronic Health Records
(EMRs/EHRs): United States, 2001-2008 and preliminary 2009
Any EMR/HER system
50
Basic system
45
Fully f unctional system
41.5
43.9
Percent of Physicians
s
40
34.8
35
29.2
30
23.9
25
20
20.8
18 2
18.2
17.3
20.5
17.3
16.7
15
10.5
11.8
10
5
31
3.1
38
3.8
4.4
2006
2007
2008
6.3
0
2001
2002
2003
2004
2005
2009
Year
Source: National Center for Health Statistics, December 2009
Basic system: patient demographics; patient problem lists; clinical notes; orders for
prescriptions;
p
p
; imaging
g g results
Fully functional system: basic plus medical history and follow-up; orders for tests;
prescription and test orders sent electronically; drug interaction warnings/contraindications;
highlighting out-of-range test levels; reminders for guideline based interventions
U.S. Primary Care Physicians Slow in Adopting Care
Management Tools to Treat Patients with Asthma,
Congestive Heart Failure, Diabetes and Depression Across
Conditions, 2008
Did not use tools
for any of 4 conditions
Used for
1-3
1
3 conditions
Used for
all conditions
Tools
Written
Educational
materials
t i l
24%
Nurse
managers to
coordinate care
69%
22%
10%
Non-physician
Non
physician
educators
50%
35%
15%
Group visits
80%
16%
3%
31%
45%
Source: Center for Studying Health System Change, December 2009
Characteristics of Patient Visits
to Retail Clinics and PC Practices
% Retail Visits
Visits
Proportion among the 10
most common reasons for
visits to retail clinics
% PCP
90
18
Examples:
upper respiratory infections
pharyngitis
p
y g
immunizations
otitis media or externa
27
21
20
13
14
2
1
3
Primary source of payment – OP
33
10
Reports not having a PCP
61
------
Source: Mehrotra et al. Health Affairs, 27(5): 1272-1282, 2008
Areas of Needed Adjustment
• Revised reimbursement arrangements – paying for
performance not q
p
quantity
y of services;; p
paying
y g fairly
y
for care management and cognitive services
• Reduced pace and more time for direct patient care
• Improved use of teams and coordinated care processes
• Reimbursement for care management and coordination
• Improved teamwork
• Rapid adoption of EHRs
• Evidence-based focus while protecting physician autonomy
• Building improved group cultures and managerial support
Proposed solutions (Medical Homes, ACOs),
will be difficult to implement widely without
fundamental changes in organization, professional
culture,
lt
financial
fi
i l iincentives
ti
and
d managerial
i l lleadership
d hi
Range of Successful Models
• Kaiser Permanente
●
GHC of Puget Sound
• Geisenger Health System
Proven Health Navigator
PCMH Model
●
Virginia Mason
●
Johns Hopkins Guided
Care PCMH Model
• Intermountain HealthCare
Medical Group Care
M
Management
t Plus
Pl PCMH
Model
Likely Future:
Slow Progress
Progress, Short
Short-Term
Term Difficult
• Mixed models of varying effectiveness and quality
• Increased use of nurse practitioners, PAs, new care
provider roles, retail clinics, community health centers,
Internet assisted self-care
__
__
__
__
__
__
__
__
__
Given the diversity of contexts, tough finances and politics,
and the need for multiple pragmatic approaches and
solutions, it is likely we will slowly muddle through in baby
steps but hopefully evolve in more rational, acceptable,
and
d equitable
it bl care patterns
tt
over th
the nextt 20 years
Practice Redesign
Plausible Redistribution of Functions for Added Value –
Most Likely in Integrated System
FUNCTION
U C O
Routine established services
(e.g., immunization, common
acute complaints))
FROM
O
PCPs
TO
O
retail clinics; NPs; PAs;
medical technicians
Continuing management of
less complex chronic diseases
and comorbidities
Subspecialists
PCPs; PC teams; NPs
Basic primary care provided by
subspecialties (estimated several
hundred million annual encounters)
Subspecialists
basic levels of care
depending on complexity
Emergency room – 1st contact
primary care
Chronic disease management
counseling and instruction
Complex chronic care and
complex comorbidities
ER
Subspecialists
and PCPs
PCPs
urgent care clinics; retail
clinics; NPs; PCPs
properly designed chronic
disease management teams
subspecialty teams
System Coordinated Through EHRs