'More Primary Care' Not Enough, Says Speaker

"My practice was becoming more about producing volume, and less and less about caring for patients." That's the assessment L. Gordon Moore, M.D., recently made about the state of his solo family medicine practice in 2004.

That same statement probably holds true for many family physicians today.

Moore was speaking to an audience of nearly 150 family physicians, other clinicians, educators and office administrators at the Conference on Practice Improvement: Health Information and Patient Education, held here Nov. 9-12. The conference was presented by the AAFP in partnership with the Society of Teachers of Family Medicine.

"I needed to solve some fundamental problems so I could get back to healing," said Moore. "I'm hoping that my work will help you in the work you're doing," he told audience members.

A clinical assistant professor in the departments of Family Medicine and Community and Preventive Medicine at the University of Rochester, New York, School of Medicine and Dentistry; a leader in Rochester's "Reweaving the Safety Net" project; a core faculty member of an Institute for Healthcare Improvement project studying ambulatory and academic practice; and a principal investigator studying the Ideal Micro Practices movement, Moore got to the point quickly, naming numerous studies that highlight the shortcomings of the U.S. health care system. He repeated the findings from one report that concluded the U.S. health care system -- in its current model -- is incapable of sustaining itself.

It's clear that the insufficiencies in America's health care system are not caused by physicians' lack of effort or lack of professionalism, Moore noted. "It's not because we are not trying or don't care," he said.

According to Moore, legislators are desperate to do something different, but the ideas they introduce have early face value and bad long-term consequences. "Well-intended policies are failing us because we're not addressing the fundamental problems in health care through these maneuvers," he said. "We're paving the road to hell with these well-intended maneuvers."

Moore told his audience that although they had work to do, the answer was in the room. "It's primary care," he said, "and we have the means to do it if we're given the changes in financing, rules and governing needed."

But is the answer just to throw more money at primary care? It would seem so, said Moore, when comparing the United States to other countries heavily invested in primary care.

However, he asked, "If we get more of what we already have, is that enough? Is it merely a matter of more primary care," when patients aren't getting the care they need from the primary care now provided to them? Moore cited a survey published in the New England Journal of Medicine in 2003 that concluded just 54.9 percent of surveyed adults living in 12 metro areas in the United States received the recommended level of health care.

"We're trying to get folks to move to the new care model, but without financing, it's not possible," said Moore. Furthermore, measuring outcomes on a disease-by-disease basis -- as is currently being done with chronic diseases such as asthma and diabetes -- is inefficient because of the number of data elements that have to be tracked, he said.

Moore says he can deliver higher quality patient care with more efficiency and less cost by surveying patients to assess their levels of need. In his practice, he said he conducts this survey using three simple but key questions:

Having that information allows Moore to segregate patients based on low-, medium- and high-level needs. And doing that enables the practice to allocate its resources to the group of patients most in need of those resources, he said.

Moore explained that low-needs patients can be trusted to take health care information provided to them and follow through on their own. On the other hand, "We've learned that a patient with medium needs responds well to telephone intervention," said Moore. For instance, three follow-up phone calls from a staff person designated as a practice's telephone coach can dramatically improve a patient's chronic pain.

As for that last group, "We ramp up our outreach with high-needs patients … we're throwing a lot of resources their way," he said.

Important changes are on the way, according to Moore. "Now we're making the case (for change) with the employers, the people with the money," he said. Pilot projects are needed to show that physicians should be paid for making key structural changes in their practices and for attaining results. And, he added, information about those results should be attained through patient self-reporting. The current method -- collecting subsets of data -- does not report any meaningful information, he said.

The issue at hand is not so much to create an awareness of the need for primary care as it is to change the delivery of primary care, said Moore in response to a question from the audience. The new model "cannot be more of the same." Rather, he said, it's got to have new and different elements.

"It's hard to have a seat at the table if you're not doing due diligence in your own practice," he concluded.