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Centering on…Ten Strategic Shifts for Primary Care Medicine
Across all of the health professions we face a daunting challenge: how
can we change the dominant practice model to become more adaptive to the
access, quality, and price demands of, patients, payers and the public,
while simultaneously operating the old model at full speed in order to
make ends meet? The lack of regulatory and financial incentives does not
encourage the needed change. If that were not enough, there are few clinicians
who are skilled in such transformations and the experience base gets thinner
the smaller the organization or practice is.
The challenges exist from medicine to dentistry to optometry to nursing,
but seem most acute and pressing in ambulatory primary care medicine.
At a time when these practices feel themselves besieged, it is difficult
to know where to begin and how to proceed with a set of changes that ask
for nothing less than wholesale reform. Here are my ten suggestions of
where the lever might be placed first.
- Move from an acute focus to a chronic orientation.
There is certainly nothing new in this suggestion, but the current movement
of primary care from its acute curative orientation to a chronic management
focus is not keeping pace with the rate of the aging population. More
dramatic shifts and perhaps exclusive focus on this by younger primary
care physicians may be necessary if there is to be an adequate capacity
to address the emergent disease burden.
- Understand consumer preferences and the price points for their
purchases.
Hope still springs that there will be a sweeping reform of health care
and that a single payer at the state or national level will reimburse
all providers for the care they feel their patients need. While such
a scenario is still possible, it seems far more likely that patients
will be forced to make arrangements for high deductible insurance that
will protect them from financial loss associated with an expensive episode
of care, but encourage them to shop around for their day in and day
out care from a primary care provider. This means that to remain viable,
practices must begin to understand not only what their patients need,
but what they want as customers and what they are willing to pay. Some
will want concierge service and no waiting, others will not mind waiting,
but will expect a break in price, particularly if they can schedule
in off hours. Americans have demonstrated a great capacity to pay for
things they perceive have value, which is a highly dynamic combination
of price and quality. Physician leaders must have a better understanding
of the product and service that they are bringing forward and be willing
to be a bit more entrepreneurial with it.
- Move the focus for delivery from the physician to the team and
system.
The foundation of medical practice is the doctor-patient relationship,
but the nation can no longer afford it to be managed in 18 minute increments
in the exam room. New and more effective ways to meet the needs of patients
by using teams and systems must be devised.
- Balance point of service with range of services for self care,
home-family care and community care.
Once focus for delivery shifts from the physician to a team or system,
doctors will be better able to assess when patients really need their
medical expertise. Not surprisingly, this will happen less often in
the exam room. As the mobility and health status of the population changes
and the cost of institution-based care, even a clinic visit, grows it
will provide many physicians the opportunity to move their services
where they are most needed. Of course much of this expertise will be
moved around in the virtual space, but one can easily imagine a patient
receiving a physical at home less expensively than visiting the office,
particularly if the office overhead did not exist.
- Transition from an exclusive focus on service to a balance of
procedure and knowledge.
As the financing of care shapes its demand and changes the location
of delivery, the actual service provided by the primary care physician
may more easily migrate to knowledge-based services and away from the
necessity of the procedure. There is a sense among primary care physicians
that they are ready for this as soon as the reimbursement switches are
thrown. A counter perspective would have the provider lead in demonstrating
what these arrays of services are and how they could be financed, including
direct patient pay for service. It may be that the payment policy will
not move until it is demonstrated in action.
- Use information technology to drive population orientation.
There is considerable interest and investment in information technology
today, particularly around the electronic patient record. However, if
this record just speeds up the existing process, but does not radically
break the current mode or practice, it will be a very expensive boondoggle
that ultimately becomes less than it promised. The drive to e-health
should lead to basic business process improvements, but these have to
be done in the context of population orientation.
- Address generalist-specialist communication.
The public of course assumes that generalist-specialist communication
is seamless already. However, when we examine it closely there are enormous
transaction costs in this relationship; Poor generalist-specialist communication
can lead to monetary costs, not to mention the deterioration of patient
safety and consumer satisfaction. If primary care is going to work it
needs this transaction to work better than it does today. It must be
timely, while affording an opportunity for the provider to play an appropriate
role and return to the primary practice in an integrated manner. Each
of these will require that the specialist community reconsider its relationship
with primary care. The best places for this are multi-specialty group
practices. If the other forms of organizing medial practice are to be
sustained, this issue will have to be addressed front and center.
- Involve non-physician practitioners deeply in the organization
and delivery of care.
In my experience the hardest thing for a primary care doctor to give
up is the contact with patients. But at some point the system must ask,
and the doctors must respond to, the question: what is the objective
value of this interaction to the patient? There will always be a need
for patients to see the doctor, just not every time. Primary care physicians
must build practices that embody their professional values and ethics
and even their clinical skills in ways that do not require having them
in the exam room for every encounter. This transition will be the most
psychologically taxing change of all the suggestions proposed here,
but it is essential if medicine is to stay in primary care.
- Alter the practice model in collaboration with the patient/consumer.
Related to the last point is the need to reconsider the role of the
patient in the delivery of health care in a primary care practice. For
years we have been blaming the physician when patients did not do their
part. It is now time for primary care to get aggressive with a kind
of smart tough love for patients, breaking down some of the co-dependency
that has emerged. Without honestly addressing this issue, primary care
will not have a role as more and more of care and health moves out of
the hospital and the clinic.
- Create a system of continuous innovation and improvement.
None of these suggested actions can happen overnight. Integrating these
changes will require each primary care practice to commit to a decade-long
process in which small experiments are attempted, progress assessed
and learning acknowledged and applied to the next small experiment set.
This is of course daunting, but continuous small scale improvements
have proven themselves to be what real change needs to embody to be
successful.
To e-mail Ed O'Neil, please click here.
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- To email Ed
O'Neil, click here.
- To read Ed O'Neil's bio, click here.
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