Primary care physicians tend to a wide range of needs for their patients, and new payment models must be structured to recognize the value of such care, according to speakers at a recent policy forum.
Kurt Stange, M.D., Ph.D., editor of Annals of Family Medicine and a professor of family medicine, community health, epidemiology, biostatistics, oncology and sociology at Case Western Reserve University, discusses his experience caring for a patient with multiple chronic conditions.
Speakers at the Graham Center Primary Care Forum titled "Achieving Effective Team-Based Primary Care in an Age of MACRA & Measurement" held at the U.S. Capitol on April 26 said the new payment models are only beginning to address the need for greater overall spending on primary care and a sharper focus on team-based care.
Kurt Stange, M.D., Ph.D., editor of Annals of Family Medicine and a professor of family medicine, community health, epidemiology, biostatistics, oncology and sociology at Case Western Reserve University, talked about the complexity involved in caring for his patients. Stange described one patient, a man who spent a lot of time working on his car. He went with his wife to see Stange about pain in his shoulder. Stange advised him to cut back on tinkering under the hood, prescribed medication and a stretching regimen, and told the man to return in three weeks if the pain persisted.
The man returned weeks later with the same pain. His back was in spasms when Stange entered the exam room. Noting the pain's intensity, Stange ordered a CT scan. It was an unusual move but proved to be the correct call, as it revealed cancer of the esophagus, an aorta that was near bursting and a cancerous bump on his kidney.
- Speakers at the Graham Center Primary Care Forum recently discussed new payment models and team-based care.
- Payment must support the complexity of primary care patients, a speaker said.
- An attendee pointed out that fee-for-service payment does not support team-based care well.
"Of all of those things, what do I do first?" Stange asked.
Stange referred his patient to a gastroenterologist and a radiologist, and eventually the man's esophagus was removed. Stange and the medical team decided to keep his blood pressure as low as possible. It was a contravention of medical protocol, but valuable for both the patient and the health care system.
"If you save a little in term of reduced hospital stays, you can pay for a lot of primary care," Stange said.
The complexity grew as Stange's care in the case extended beyond the specific patient. The man's wife also reported declining health, specifically arthritis and depression, so Stange advised the couple to take nightly walks and helped the man prepare a living will.
Erin Sullivan, Ph.D., research and curriculum director at the Harvard Medical School Center for Primary Care, noted that the most successful teams look beyond conventional protocol, as Stange's team did. They also delegate more tasks to medical assistants.
Discussing several primary care teams that are working successfully throughout the country, Sullivan said medical professionals other than physicians on teams can handle frontline tasks such as refilling prescriptions and triaging patients.
But new payment models must be able to support these teams. David Meyers, M.D., chief medical officer for the Agency for Healthcare Research and Quality, said spending on primary care should rise sharply from the current level of 4 to 6 percent of total health care costs in order to fund infrastructure improvement that primary care health teams require. He moved to a research career after years of working in community health centers so he could advocate for such policy changes that benefit primary care.
Meyers, a family physician, emphasized that the transition to a comprehensive care model needs to incorporate more than just cost reduction strategies. Improving overall population health needs to be added to the measurements of success.
"We're real good in the U.S. at finding answers to clinical questions," he said. "We're less good at taking the advances made by the NIH and delivering them to all Americans."
Larry Green, M.D., a professor of family medicine at the University of Colorado who attended the event, said teams are not a new concept in primary care but the fee-for-service payment model does not support team-based care well.
"You don't hear patients saying, 'I want an ACO (accountable care organization)' or 'I want a PCMH (patient-centered medical home),'" Green said. "They say, 'Where can I find a good doctor?' But in the fee-for-service environment, if the doctor doesn't see patients, there's no revenue."
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