As the Chief Medical Officer for Martin’s Point HealthCare, a Maine-based not-for-profit organization, and a practicing family physician for 18 years, I am acutely aware of the many challenges confronting traditional primary care medicine. These well-described threats — which do not serve patients, providers, or payers well — include but are not limited to:
- waning enrollment in primary care residency programs in the U.S.
- growing dissatisfaction among primary care doctors, often leading to burnout and early retirement
- look-alike competitors to primary care in retail, telehealth, and urgent-care settings
- concierge primary care practices that serve only affluent patients
- wide variation in population health, patient experience, and total costs across primary care service areas
Despite these challenges, hopeful signs are emerging. I’d like to share some of the incremental approaches that my organization and others are taking, with an eye toward helping primary care professionals and leaders who seek to transform their own practices. The models I describe are works in progress, but they may nonetheless portend a turnaround for our profession and the patients we serve.
New Models in Primary Care
As we edge away from traditional fee-for-service payment models, some innovations in primary care have been prompted by support from the Centers for Medicare & Medicaid Services or through Medicare Advantage plans. New designs are grounded in the Triple Aim: improving the patient experience, bolstering population health, and lowering total costs. Progressive organizations also consider the well-being of their health care workforce (Triple Aim Plus One), with a greater focus on value instead of volume. Here’s how some primary care institutions are innovating:
Martin’s Point HealthCare. At my organization, based in Portland, Maine, we take a multipronged approach to meeting the needs of our workforce while delivering affordable, high-quality care to patients. We use the Balanced Scorecard to measure both financial and “Triple Aim Plus One” performance. The Balanced Scorecard measures and targets are set annually at the executive level and then translated into specific goals at our primary care health centers. Frontline providers and staff engage in daily team huddles, where process improvements are initiated. After a change has been implemented, performance is remeasured and further adjustments are made so that improvement is continuous. Lean management principles underpin all of these efforts.
We transparently report all measures, including patient experience and providers’ individual performance, both internally and to the public. For providers who fall short, we offer professional development, training, and even coaching that is led by our high performers. We have found that processes, not people, are the major barriers to upping our game in all aspects of the Triple Aim. Our efforts have greatly increased the level of satisfaction in our workforce, earning us recognition as one of the 2016 Best Workplaces in Health Care.
With respect to patient outcomes, our Martin’s Point Generations Advantage plans have earned 5 stars in health care quality and service for the past 2 years. Our primary care teams played a key role in this recognition by focusing on closing gaps in care, improving outcomes specifically in diabetes care, and distinguishing themselves on measures of member and patient experience. And in the spring of 2016, we initiated an intensive care-coordination program for our patients whose preventable downstream total costs are in the top 5%. Nurses, embedded in our primary care teams, coordinate with providers and link patients to critical community resources in an effort to reduce avoidable hospitalizations, emergency department (ED) visits, and mortality in this vulnerable group. (Anecdotal data on these efforts suggest that ED use and hospital admissions are declining.)
HealthBegins. Leading the efforts at this California-based organization is its Chief Medical Officer Rishi Manchanda, a self-described “upstreamist” who believes that the key to innovation in primary care is a focus on the root causes of what makes people ill, not just on treating the symptoms they present with in an examination room. He discusses how simple interventions often can help to control exacerbations of illness and improve patients’ well-being. For example, at HealthBegins, a primary care referral to a specialist for a child with asthma (whose trigger is mold) may involve securing the help of an attorney who advocates for fixing a leaky roof. In the grand scheme, $2,000 for a roof repair can prevent frequent $5,000 visits to the ED.
CareMore. In this health system, which operates in 7 U.S. states, extensivists (hospitalists who can work across care settings) collaborate with social workers and teams on daily rounds to ensure that patients move seamlessly from hospital to home. These physicians and care teams also help to optimize home-based services that allow patients to remain independent for as long as possible. At CareMore, a patient with an asthma exacerbation has a nebulizer and medication promptly delivered to her home by a trained respiratory therapist, who then helps the patient administer her treatment safely. The result: The patient avoids an unnecessary ED visit or hospitalization.
Geisinger, Intermountain, Kaiser. These major health systems, integrated with insurers, are transforming traditional primary care by embedding behavioralists and care managers at health centers, where they receive “warm handoffs” from PCPs. The PCPs can leverage their longstanding relationships with patients to encourage them to engage with social workers, psychologists, and nurses who help them navigate the complexities of the health system and community services. The affiliated insurers see better outcomes in diabetes care and lower rates of ED use and hospitalization.
The Bedrocks of Transforming Primary Care
Stepping back from initiatives at specific institutions, we can see a few commonalities in how primary care is being transformed:
Holistic, not disease-driven, care. When patients are chronically unwell, health care assessment and intervention must be tailored to each patient’s unique needs. Without considering a patient’s residential environment, working conditions, social and spiritual support systems (or the lack of them), and the behavioral context of illness, the medical interventions that support disease management will often be ineffective.
Patient-centeredness, not physician-centeredness. Physicians must become comfortable working with and supporting teams that are charged with caring for patients and families, both inside and outside health care facilities. Behavioralists, social workers, care managers, nurses, pharmacists, and advanced-care practitioners enhance and extend the care of the physician into a more coordinated system of care delivery. Primary care physicians may find that their jobs become more rewarding as they focus less on tasks that are not commensurate with their skill level and more on establishing meaningful, trusting relationships with patients and on attending to the most complex medical decisions. Physicians who can “let go” of task-oriented work to support protocol-driven, well-coordinated best practices will be most successful in these new models.
Smart use of new care-delivery venues. Another novel primary care innovation is in leveraging specialists for virtual “curbside consults.” At Kaiser Permanente in some states, for example, a dermatologist may do 100 consults a day when working directly with PCPs through an electronic interface. In effect, the specialist helps the frontline care team manage many routine cases while reserving in-person specialist visits for the most complex, unstable cases. A similar approach has been used in psychiatry for frontline primary care providers at federally qualified health centers and in pulmonary medicine, radiology, neurology, and cardiology at other organizations.
All of these efforts will, of course, require a clearly defined set of primary care performance measures, agreed upon by federal and state governments and aligned with insurers that work directly with clinical and operational leaders in primary care. These metrics should include total cost of care, quality of life, patient experience, patient access, and clinical outcomes. Organizations should commit to improving the job satisfaction of all employees, not just physicians. Data should be shared openly to promote dialogue within organizations, and also regionally and nationally. That’s a tall order for sure, but not out of reach if we create the appropriate incentives and share our successes (and failures) openly.
Efforts to transform how primary care is delivered are in their early stages. Nevertheless, my own organization and others are showing that it’s possible to take steps in the right direction — and to measure and report transparently as we go.
This article originally appeared in NEJM Catalyst on August 9, 2016.