Primary Care the 'Fundamental Building Block' for Health Care Reform

Congress and the Obama administration have reached the same conclusion about health care reform -- successful reform will not happen without a focus on primary care and the patient-centered medical home, or PCMH. That was one of the main messages delivered by a variety of federal officials during a Patient-Centered Primary Care Collaborative, or PCPCC, stakeholders meeting here on July 16.

Edwina Rogers, J.D., executive director of the PCPCC, laid out the status of health care reform. She noted that House and Senate committees have introduced bills that call for payment increases for primary care services and that make provisions for the PCMH. In the House, the Ways and Means Committee, the Energy and Commerce Committee, and the Education and Labor Committee introduced a so-called tricommittee bill (at the THOMAS Web site, type "H.R. 3200" in the search box after selecting "Bill Number") that provides $350 million for Medicare PCMH pilot projects. It also includes $1.2 billion for a five-year Medicaid medical home pilot project.

On the Senate side, the Health, Education, Labor and Pensions, or HELP, Committee has introduced legislation that would authorize grants for new education and training programs in medical schools and residency programs that support the PCMH. Although the Senate Finance Committee has not yet released its own health care reform bill, members of that committee want to include in it a PCMH pilot project similar to the one in the House legislation, said Rogers.

Meanwhile, she noted, President Obama said earlier this year that he supports the concept of the PCMH. During various speeches and town hall meetings, he has repeatedly stressed the importance of primary care as a fundamental building block of the nation's health care system.

"I predict you are going to hear (that) a lot more moving forward," said Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, or AHRQ, and one of several speakers from the federal government who addressed stakeholders during the July 16 meeting.

"Collectively, we have the opportunity of a lifetime," said Clancy. "I am very optimistic we will indeed have reform."

If Congress passes health care reform, medical home provisions are likely to be "fairly broad," leaving a great deal of flexibility in terms of implementation, Clancy said, adding, "That is exactly how it should be."

The PCMH is likely to look different in urban areas, such as Miami, than in rural or frontier areas, she said. "You don't want legislation that goes on for pages and pages that defines details to the (last) degree. What you do want is legislation that focuses on primary care."

Andrew Webber, president and CEO of the National Business Coalition on Health, seemed to agree with Clancy's statement, saying, "genuine reform really happens in local communities at the ground level." He added that the current health care system emphasizes acute care treatment and treatment for illnesses at the expense of prevention, wellness, primary care and chronic care management.

"Primary care really does need to be the spinal cord of any health care delivery system," said Webber. "We need to work with our health care partners in setting expectations, including expectations that health care plans should be using their resources to move toward medical home, medical neighborhood concepts."

Increasingly, policymakers are focusing on the ongoing crisis in primary care, the lack of adequate payment for primary care physicians and the shortage of primary care health professionals. But the crisis in primary care is symptomatic of a larger issue -- the current way health care is delivered and paid for, said Steve Wojcik, vice president of public policy for the National Business Group on Health.

"In the end that is what really matters," said Wojcik. "It is not what kind of mandates we have or what kind of public plan we have. If that is all we are focusing on and that is all we are doing, we are not going to get the kind of health care reform that we in the collaborative and we in the business community believe in."

Frank Verloin deGruy III, M.D., professor and chair of the department of family medicine at the University of Colorado Health Sciences Center in Denver, identified fragmentation as one of the biggest barriers in the nation's health care system and one that undercuts primary care.

"Our success with the medical home turns on eliminating fragmentation," he told PCPCC stakeholders. "If we don't solve that problem, we'll fail."

He added that the PCMH has to incorporate behavioral and mental health services, and he cited several studies that indicate patients with physical ailments often have corresponding mental health conditions.

"If you treat (physical and mental health conditions) together, the cost of care is much less expensive than if you attempt to treat them separately," said deGruy. "If you treat these (conditions) together, the health outcomes also are quite a bit better."

Kathryn Power, M.Ed., director of the Substance Abuse and Mental Health Services Administration, noted, "Mental health is essential to all health."

"We now have sufficient evidence that caring for people's bodies and minds in an integrated way achieves sound health outcomes and sound financial outcomes," she said.

Power also said primary health care that addresses the entire person is best delivered in a continuous and planned way in the context of a trusting and healing relationship. "The medical home best captures this idea," she told members of the collaborative.