Primary Care Breakfast Club Publishes in NEJM

We are happy to announce that the authors of Primary Care Breakfast Club published a perspective piece in the New England Journal of Medicine on September 6, 2012.  Our piece, titled "The Developing Vision of Primary Care", has received a lot of feedback from all sides.  If you are interested in continuing the conversation, feel free to leave a comment.

To read the piece, visit the following link: http://www.nejm.org/doi/full/10.1056/NEJMp1204487

We hope you enjoy and would love to hear your feedback!

Primary Care Spring

IBM is launching what they are calling the "Primary Care Spring."  At the risk of upstaging Occupy Spring they are seeking to revolutionize the way they take care of their employees by widely promulgating the Patient Centered Medical Home (PCMH).  They are certainly not the first, but they represent a growing number of large insurers that have jumped on the wagon.

In a YouTube video presentation by Dr. Paul Grundy of IBM that can be found at the above link he describes 3 trends he is seeing:

1. Cost: good comprehensive coordinated patient-centered care saves money
2. Data: we can now help physicians make better clinical decisions because we now have the data needed to do so (how could he give a presentation without mentioning "Watson"?)
3. On-line asynchronous care: medical homes succeed because they allow for on-line and asynchronous care where you don't have to see your doctor to be treated and they don't have to see you to get paid.  In this new information age our children will not put up with receiving care any other way.

In short, this is nothing new but it is all coming together across the country.  The government, insurers, employers, providers, and patients are all recognizing that accessible, coordinated, patient-centered care really does save money and make people healthier.

You CAN have your cake and eat it too.

-JKR

PBS Documentary: U.S. Health System: The Good News

PBS's recent documentary on communities in the United States that are providing high quality health care at a lower cost is inspiring and worth checking out. They highlight several communities across the nation, including Grand Junction, CO, Group Health in Seattle, and physician practices in Everett, WA. Communities are doing great things, but in isolation. This documentary shows us that we are capable of providing high quality care, efficiently and cost effectively. Hopefully, medical communities across the nation will adopt practice patterns that are similarly responsive the health needs of the population.

Check out the documentary here.

BWC

Ezekiel Predicts the End of Insurance Companies by 2020

Ezekiel Emanuel boldly proclaims that insurance companies will be extinct by 2020 in last week's New York Times article. He believes that Accountable Care Organizations (ACO) will push them out of the market. It will be interesting to follow his prediction over the next 8 years to see if he is correct.

Emanuel explains that ACOs will eventually bear all the financial risk for patient care when they are implemented which will eliminate the need for insurance companies. ACOs, which will be composed of groups of doctors, other providers, and hospitals, will work together to provide the full range of patient care. Eventually, he sees patients paying a flat rate directly to ACOs, who, in turn, will provide all services needed. The advantage of the ACO model is that it incentivizes providers to keep the patient healthy and focus on prevention, rather than provide care only at the point of illness. Additionally, it will integrate care for the patient, creating better collaboration between different providers.

At the moment, 60% of insured citizens under age 65 in the U.S. are insured through their employer. In these cases, the financial risk falls on the employer, not the insurance company. This leaves the insurers there to help with processing claims and to provide negotiating power with hospitals and doctors. However, ACOs will charge a flat premium, which should reduce the amount of administrative work required to process and file insurance claims on a case by case basis. In situations where insurance companies take on financial risk for patients’ health – such as small businesses and individuals – they have enough market power to cherry pick healthy patients, charge high premiums, and deny patients’ claims. When ACOs start being implemented, insurance companies will be competing with ACOs for these patients. This will infuse better competition and should reduce the need for patients to hassle with insurance companies over coverage.

Emanuel also breaks down the difference between ACOs and HMOs in a very concise manner. First, ACOs and HMOs are similar such that patients are members of the organization and members pay a flat fee. In other words, payment is not done on a fee for service manner in either of these models of care. However, Emanuel emphasizes that ACOs will be local groups of providers, not large national corporations like many HMOs, so ACOs will be able to better respond to local patient needs. Also, ACOs will be financially incentivized to keep patients healthy rather than only getting paid to treat the sick. Lastly, he points to the advancements in electronic medical records as well as the science of care integration as improvements since the HMOs’ day.

Personally, I am not fully convinced that insurance companies will be extinct by 2020. It may be that I do not understand ACOs to the depth that Emanuel does. But, maybe in the end, ACOs will become large enough that they will just take over coverage responsibilities as well. Time will only tell.

BWC

Can the United States Learn from Brazil's Primary Care Model?

Brazil has seen huge changes in the past several decades in their political and social structure. Prior to democratization in the 1980’s, the country had been under several decades of military rule. After the authoritarian rule, socio-political reformation began to take shape which included an overhaul of their health care system. The belief that health is a universal human right became more widespread throughout the Brazilian culture and with this in mind, the National Health System (SUS) was created in 1988 and implemented in 1990. Since implementation of SUS, Brazil has seen huge improvements in health outcomes including increased life expectancy, decreased infant mortality, and decreased deaths from infectious diseases.

A cornerstone of the SUS is the Family Health Program (PSF) which functions as their primary care delivery system. The PSF was established in 1994 as a way to meet universal access goals, better coordinate care, and focus on prevention. The PSF’s focus is on family and community health which encompasses prevention and public health goals. Under PSF, family health teams, which consists of one doctor, a nurse, an auxiliary nurse, and 4-6 community health workers cover a geographic area which includes no more than 5,000 patients. Community health workers are vital to the team as each community health worker is responsible for about 120 families and they make home visits to each of these families once per month. The community health workers’ primary focus is on child and maternal health, but they have been instrumental in health promotion, education, medical adherence, public health actions (i.e. sanitation), chronic disease management, and triage support.

The PSF is highly decentralized with most authority placed on the municipalities. The PSF program has been successful in getting to the majority of the population as family health teams are found in 85 percent of municipalities serving over 98 million people. Despite the large coverage, the PSF program only takes up 8 percent of the federal health care budget.

The PSF program has been shown to be very effective in improving health outcomes for Brazil. Access to care has increased by over 25 percent since its origination in 1994. Life expectancy has increased from 67 to 72 years, immunization rates for Tetanus, Diphtheria, and Pertussis is over 95 percent for all children 1 year of age, and infant mortality has decreased from 48 per 1000 to 17 per 1000. A reputable study by Guanais and Macinko focused on postneonatal mortality as a proxy to assess success of primary care delivery. It is argued that the postneonatal period, ranging from 30 days to one year, reflects success in primary care goals of nutrition, immunization, sanitation, breast feeding, and prevention of respiratory and diarrheal infections. They found that between 1998 and 2006, the postneonatal death rate decreased from 14.24 to 6.92 per 1000 children while at the same time PSF coverage increased from 8.74 percent of municipalities to 60.90 percent. Their published paper accounted for increases in clean water, decreased illiteracy rates, and other confounders and through regression analyses determined that the family health teams decreased postneonatal death rates by 0.86 per 1000 compared to communities without teams.

The PSF does not come without some problems, however, and need to be mentioned. The decentralized nature of the program makes it difficult to ensure quality between geographic regions. The federal government collects money, but the money is allocated to municipal governments who are ultimately in charge of managing their budget and health care delivery. Problems seem to arise most in the northeast region which is more socioeconomically depressed than the central or southern regions. As a result, the northeast has a higher infant mortality rate, more deaths from infectious diseases, and lower life expectancy. Not surprisingly, many municipalities in the northeast do not have family health programs, partly because it is difficult to recruit and retain health providers for this region. Additionally, corruption is a problem with some municipalities which results in allocated money not being used for health care expenditures. These problems create conspicuous disparities in access and health care outcomes between different municipalities.

Another problem faced is the difficulty of integrating the family health teams with local hospitals and specialist care. Some municipalities have more success than others in working with the private sector. Naturally, the more coordinated and integrated the care is, this results in better available health care for Brazilians. Lastly, the emphasis on improving primary care has come at the sacrifice of providing good hospital and tertiary care. Brazil’s public hospital system only provides 35 percent of hospital beds in the country with the remainder made up of by private hospitals. The public hospital system is overcrowded and has large variability in quality.

As the United States works to come up with solutions for improved primary care delivery and access, it may be prudent to look outside of Europe and Canada for ideas. Arguably, Brazil’s primary care model has seen some of the greatest health improvement of any country in the world through their innovative decentralized method. I feel that U.S. could benefit from a team based approach. Teams are seen to an extent in our patient centered medical homes, but the addition of community health workers could facilitate improved chronic disease management, health promotion, behavior change and support, and medical adherence. Most importantly, Brazil has shown us that by investing in primary care, the health of the population can be greatly improved. As we continue to work towards improved health systems and primary care delivery, let’s not forget to keep Brazil in mind.

BWC

Resources:

Frederico C. Guanais and James Macinko, The Health Effects of Decentralizing Primary Care in Brazil, Health Affairs, 28, no 4 (2009): 1127:1135

Michael Kemp, Cracks Appear in Brazil’s Primary Health Programme, The Lancet, vol 372 (2008): 877

Mathew Harris and Andrew Haines, Brazil’s Family Health Program, BMJ 2010; 341: c4945

Paim, J., Travassos C., Almeida, et al., The Brazilian Health System: history, advances, and challenges, The Lancet, 2011; 377: 1788-97

Innovation in Physician Training

Patient-Centered Medical Homes (PCMH’s) are presented as a care delivery innovation that has had success in the realm of increasing quality of care while decreasing costs. At its core, the PCMH seeks to strengthen primary care, leading to coordinated care, improved access, and ultimately reduced costs. However, the dark irony of the success of the PCMH model is that as primary care demonstrates its ability to serve as a hub for care coordination while reducing cost, primary care physicians (PCP’s) are dwindling in proportion of the physician work force. Perversely designed fee schedules have created a dramatic income inequality among physician specialties, strongly steering medical students away from generalist careers. While many factors ultimately influence student specialty choice, medical students are hard pressed to choose generalist careers while income disparity remains so troublingly wide.

Further, essential to the success of PCMH’s are functional teams. Looking at the results of the 2006 Group Health Cooperative model, strong PCP leadership was identified as a critical factor for the success of organization transformation into a PCMH[1]. However, current undergraduate and graduate medical training does not search out these skills in its applicants, nor does it provide comprehensive education for how to develop these practice tools. Strong leadership capable of excelling at the challenges of practice management are necessary for PCMH’s to become a widespread national success story, yet medical education has not responded to the growing need for these additional physician skill sets. Biomedical science training and clinical knowledge, the current mainstay of medical education, is not enough to produce physicians competent for current health challenges. Physicians, especially PCP’s, must be taught how to work and lead within teams, manage practices, motivate members of the care team, integrate health IT, and adapt quickly to practice innovations. These competencies are critical for the success of PCMH’s and ultimately care delivery transformation.

The reported success of PCMH’s is exciting; though many details need to be ironed out to rigorously define the characteristics of successful models, the early victories among differing patient populations provide evidence that the key organizing principles of the PCMH are widely applicable across our nation. However, to achieve this dream of coordinated, high value care, it is necessary to rethink medical student training and physician payment. Large income disparities are not sustainable if we are to attract the number and quality of primary care doctors necessary to lead transformation in care delivery. Further, medical education itself must innovate in order to equip its graduates to practice within these new models.

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[1] Robert J. Reid, Katie Coleman, Eric A. Johnson, Paul A. Fishman, Clarissa Hsu, Michael P. Soman, Claire E. Trescott, Michael Erikson and Eric B. Larson The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers Health Affairs, 29, no.5 (2010):835-843