Health Care for All: A Framework for Moving to a Primary Care-Based Health Care System in the United States
The health care system in the United States is a non-system of uncoordinated, fragmented care, emphasizing intervention, rather than prevention and comprehensive management of health. Health care costs are rapidly increasing, access is declining, and quality is far from ideal.1
The number of uninsured people in the United States is staggering, approximately 45.7 million according to the US Bureau of the Census of 2007.2 While the number decreased slightly from 2006, because of additional children eligible for the State Children’s Health Insurance program, the number of people insured through their employers decreased. Ensuring that all people in the United States have health care coverage is essential to moving toward a healthier and more productive society. However, as noted by the Commonwealth Fund, the design of a system to provide health care coverage to all people “will have a deep impact on its ability to make sustainable and systematic improvements in access to care, equity, quality of care, efficiency, and cost control.”3
The key to change is to reinvigorate the primary care infrastructure in the US, to redesign the manner of primary care delivery, and to re-emphasize the centrality of primary care. Compelling research indicates that the ever-increasing focus of resources on specialty care has created fragmentation, decreased quality, and increased cost. Studies confirm that if primary care practices redesign how they operate such that they are more accessible, promote prevention, proactively support patients with chronic illness, and engage patients in self-management and decision-making, health care quality improves along with the cost efficiency of care.4
Primary care is the only entity charged with the longitudinal continuity care of the whole patient, and it is the primary care relationship and comprehensiveness that has the most effect on health care outcomes. However, the current United States health care system fails to deliver comprehensive primary care because of the way primary care is financed.
According to the Center for Evaluative Clinical Sciences at Dartmouth, states in the US that rely more on primary care have lower Medicare spending (inpatient reimbursements and Part B payments), lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor) lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians), and better quality of care (fewer ICU deaths and a higher composite quality score).5
The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, adults and the elderly. The PCMH is a health care model that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family. Each patient has an ongoing relationship with a personal physician trained to provide first contact then continuous and comprehensive care. The personal physician leads a team of individuals at the practice level, and beyond, who collectively take responsibility for the ongoing care of patients.6
Fundamental change is required to shift the direction of the US health system toward one that covers all people and emphasizes comprehensive primary care and coordinated care through the patient-centered medical home. Resources must be deployed to achieve the desired results. Payment policies must change. Workforce policies must be addressed to ensure a strong cadre of family physicians, other primary care physicians and non-physician clinicians so integral to a high functioning health care team. Congress must enact comprehensive legislation to achieve this change. If Congress only addresses the uninsured and fails to fundamentally restructure the system to promote family medicine and primary care, a solution will not be reached.
To provide health care coverage to everyone in the United States through a primary care based system built on the patient-centered medical home.
- Everyone will have health care coverage, including catastrophic protection
- Everyone will have a patient-centered medical home
- Health care will be a shared responsibility of individuals, employers, government, and the private and public sectors
Everyone in the United States will have health care coverage. This will be achieved only if Congress enacts legislation requiring health care coverage for all, with a primary care benefit design featuring the patient-centered medical home, and a payment system to support it.
The patient-centered medical home, as described in the Joint Principles of the Patient-Centered Medical Home, will be the basis of the health care system. Patient-centered medical homes will be designated by a process such as the Physician Practice Connection – Patient-Centered Medical Home® recognition program of the National Committee on Quality Assurance (NCQA).
Primary care will be provided through the patient-centered medical home with benefits provided in the following manner:
The following services will have no financial barriers (co-payments):
- Primary care provided by or through the medical home
- Prenatal care
- Well-child care
- Basic mental health care
- Evidence-based preventive services
- Chronic care management
- Hospice Care
- The following services will have shared financial responsibility (co-payments) UNLESS they are coordinated through the patient-centered medical home:
- Durable medical equipment
- Emergency department visits
- Consultations and referrals
- Diagnostic tests and procedures
- Long-term care
- Other ambulatory-based care such as outpatient surgery and procedures
- The following services will be the financial responsibility of the patient:
- Elective Cosmetic procedures
- Dangerous therapies
- Therapies whose risks outweigh their benefits
- Coverage will include protection from financial ruin from health care costs above a specified level of out-of-pocket spending.
The payment structure will be based on the following blended payment model:
1. Fee for Service
Fee-for-service payments will continue for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described below, should not result in a reduction in the payments for face-to-face visits). These payments encourage physicians to remain accessible to patients.
2. Care Management Fee
All levels of patient-centered medical homes will receive payment, through a care management fee. The amount of the fee will increase for each of the levels of designation as noted above in the discussion of the patient-centered medical home. The monthly care management fee will reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit, and coordination of care both within a given practice and between consultants, ancillary providers, and other health care providers. The care management fee should support adoption and use of health information technology for quality improvement and provision of enhanced communication access such as secure e-mail and telephone, recognize the value of physician work associated with remote monitoring of clinical data using technology, and take into account case mix differences in the patient population being treated within the practice. Further, the payment model will be supported by better coordination of care associated through the patient-centered medical home.
3. Pay for Performance
A performance-based payment will recognize achievement of quality and efficiency goals through pay for reporting and pay for performance mechanisms.
This framework to move the United States toward a primary care based health care system where all people have coverage, are provided a patient-centered medical home, have primary care-oriented benefits and are protected from financial ruin can be achieved only if Congress acts to ensure that these policy objectives are implemented. All people in the United States must have health care coverage, but this is not sufficient to address issues of access, quality and cost. A fundamental change in the health care system to move toward a primary care based system is essential to improvements in access, quality and cost. Extensive worldwide research supports the value of a primary care based health care system in which all people are covered.7 The framework is grounded upon the documented value of primary care in achieving better health outcomes, higher patient satisfaction, and more efficient use of resources. Only through this framework of health care coverage for all that is foundationally built on primary care with the patient-centered medical home as the basic building block will the United States achieve the type of health care system that our people need and our Nation deserves. (2008)
- Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, Washington, D.C., 2001 and To Err is Human: Building a Safer Health System, Institute of Medicine, Washington, D.C., 1999.
- U.S. Bureau of the Census. Income, poverty, and health insurance coverage in the US. Washington, DC: U.S. Department of Commerce, Bureau of the Census:2007.
- Collins S, Schoen C, Davis K, Gauthier A, Schoenbaum S. A Roadmap to Health Insurance for All, Principles for Reform. The Commonwealth Fund, October 18, 2007.
- The Patient Centered Medical Home – Employer’s Guide. Patient Centered Primary Care Collaborative, 2008.
- Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006
- Joint Principles of the Patient Centered Medical Home, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, 2007.
- A summary of evidence may be found at http://www.pcpcc.net/document/evidence-quality(www.pcpcc.net).