Rather than waiting for the health care system to change, many primary care practices are taking bold steps to transform patient care and the patient experience on their own.
Thomas Warcup, D.O., medical director for Carolina Advanced Health, discusses how sharing key data with insurers improved patient outcomes at a briefing by the Health is Primary campaign from Family Medicine for America's Health.
A panel of physicians detailed some of this innovation in primary care in a March 23 briefing on Capitol Hill cosponsored by the Health is Primary campaign(healthisprimary.org) from Family Medicine for America's Health(fmahealth.org) and the Primary Care Caucus.
Rep. Joe Courtney, D-Conn., co-chair of caucus, which advocates for policies that promote the goals of enhanced primary care and payment reform, set the tone by emphasizing the importance of primary care.
Panelists said key elements of successful innovation in primary care are effective collaboration and redesigning practices to meet patient expectations. But while primary care practices are doing this work, acute care is what's getting attention, said FMAHealth Board Chair and former AAFP President Glen Stream, M.D., M.B.I.
"We're investing in severe medicine, but what really makes a difference is incremental primary care and prevention," Stream said. "We will all need primary care at some point in our lifetime."
- A panel of physicians discussed how innovation is improving primary care during a March 23 briefing on Capitol Hill held by the Health is Primary campaign from Family Medicine for America's Health.
- One panelist described how greater collaboration between primary care practices and insurers can help physicians make clinical decisions and can help the insurer control costs.
- Changes such as expanding the primary care team do not require a larger building and more full-time staff, another panelist said.
Primary care practices and insurers can collaborate better if both parties share information that helps the physician make clinical decisions and helps the insurer control costs.
Panelist Thomas Warcup, D.O., medical director for Carolina Advanced Health, described how this can work. Rather than simply exchanging claims data with Blue Cross Blue Shield of North Carolina, Warcup's practice receives specific information about when and where patients fill a prescription and is notified when new medications are introduced. And as a medical home that has a high level of trust with the insurer, the practice does not struggle with preauthorizations for needed services such as imaging.
Aside from working with insurers, primary care practices also need to draw closer to subspecialists and share responsibility for the entire spectrum of care.
"The culture has to change," Warcup said. "We have to say, 'You are our patient,' and not say, 'You are my patient.' In the past, a cardiologist would say, "Why would I want to talk about immunizations? That's not my area.'"
Emphasizing care coordination requires substantial physician time and improves patient outcomes, yet fee-for-service payment models do not reward the work.
"Many of our duties are not reimbursable" under fee-for-service payment, Warcup said. "The insurance companies are happy if you do it for free, and maybe they will send you a Christmas card."
Expanding the primary care team improves patient care, but it does not have to require a larger building and more full-time staff. Practices may be able to add, for example, a behavioral health specialist and a pharmacist to the team by bringing them in "virtually." Care coordination should be thought of as a concept and not a place, said panelist Tom Agresta M.D., M.B.I., director of clinical informatics at the University of Connecticut's Center for Quantitative Medicine in Farmington.
Agresta said electronic consults are a highly efficient way to work with some subspecialists. He noted that Medicaid patients in Connecticut often wait eight to 14 months for an appointment with a dermatologist. But if a patient visits a primary care practice with a rash, the team can send an image to a dermatologist, get a response by the next day and schedule a referral within a few weeks.
Hearing From Patients
Now that insurers are including patient satisfaction in performance measurements, practices need to gather feedback strategically. The Connecticut Institute for Primary Care Innovation (CIPCI) does so through a Patient Architects program(www.cipci.org) that trains individuals to evaluate interaction between primary care teams and patients, as well as overall staff behavior. After a site visit, they catalog their findings for practices on a large whiteboard.
The program has had tangible effects. For example, it led one practice to opt for a sliding glass window in the reception area instead of bulletproof glass with a small opening because patients said the heavy glass made them feel isolated.
"Make it high-tech, but keep it high-touch," is how CIPCI Co-director Jeri Hepworth, Ph.D, described the ideal modern primary care office setting.
Or, as Warcup put it: "Every patient wants a highly resourced practice with a country doctor feel."
Agresta suggested that practices discard the waiting room atmosphere in favor of what he called the "patient engagement center." Instead of waiting idly before a consult, patients can use the area to be educated or to update their medical records.
Recruiting for Primary Care
As the demand for primary care physicians rises, said Mary Hall, M.D., chief academic officer for Carolinas HealthCare System, a benchmark for successful health outcomes can be met if 40 percent of an area's physicians are in primary care. But today only 33 percent of physicians are in primary care, and the ratio of students choosing the specialty is just 16 percent.
Helping residents decide to go on to practice in rural and underserved areas is especially tough.
One step that helps is training residents where they are needed, Hall said, noting that residents who train in a rural area are more likely to choose to practice there after their training is complete.
After the closure of the local hospital in Anson County, North Carolina, a low-income region with poor health outcomes, a community health center opened to provide primary care, an ER and operating facilities. A team of community health workers was trained to understand the needs of local residents. Now, to acquaint them with rural medicine, family medicine residents from the University of North Carolina at Chapel Hill School of Medicine spend a month at Anson Regional Medical Services.
"Getting physicians to work in rural areas is a complex problem that we have been working on for 30 years," Hall said.