The Best Care Anywhere

I recently had an interesting encounter with a long time friend and colleague who left his private practice of family medicine and started work for the Veterans Health Administration in one of their new community primary care centers. "How's it going", I asked. "Are you happy in your new position?" I believe that his answer to me is something that everyone needs to hear.

My friend explained that the uncompensated hours he used to spend in his private practice dealing with administrative issues, multiple insurance requests, and conflicting drug formularies are now a thing of the past. "Unlike my life in private practice, my time is now completely devoted to the care of my patients, and collaboration within the practice on how to make our care better. I have scheduled time throughout the day to catch up on needed paper work and administrative duties, and we also have planned collaboration sessions with other VA health care professionals to learn and plan our team work for patient care".

The VA, once maligned in previous generations, has been quietly at work, transforming itself into what many now believe is the the highest-quality healthcare provider in the United States. They have done this by emphasizing access to primary care, creating health care teams that learn how to coordinate their care, and paying attention to the scientific evidence of what does and does not work for patient benefit. As a result, our United States Veterans Health Administration has become the only fully functioning, evidence-based healthcare system in the entire country.

Unfortunately the transformative changes in the VA are impossible to duplicate in our current private system, because of the way our current system is set up. As a doctor who works on healthcare improvement issues everyday in the real world, I have learned that the biggest barriers I face are insurance companies and the lack of planning and coordination among those who work in healthcare.

So, what are the lessons for us who struggle outside of the VA system as we plan for healthcare reform? For me, the answer seems clear:

Personal medical home - use this full service , primary care model as the template to deliver and organize our care
Payment reform - value the doctor's time and reward quality instead of volume
Use information technology - in a systematic and intelligent way to track care, identify outcomes and interact with our patients
Plan intelligently - so that needed access to care is available
Allow doctors time - for the planning and care coordination that is so necessary to improve their care and so undervalued today.

A great book to learn more about the change in the United States Veterans Health Administration and how it compares to our overall health care system is Best Care Anywhere: Why VA Health Care is Better Than Yours, by Phillip Longman.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

Medical Home Accredidation Process Now in Place

The Patient Centered Medical Home is a medical practice that facilitates a partnership between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by information technology, health information exchange and other means to assure that patients get the indicated care at the time and in the way that they need and want it, in a culturally appropriate manner.

The concept of the personal Medical Home reflects input from the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA).

Now the National Committee for Quality Assurance (NCQA) has released standards for patient-centered medical homes. This means that health care providers and purchasers now have a means to recognize these practices and assess the add value added to patient care.

At present, few physician offices in primary care specialties, would likely qualify for recognition as a patient-centered medical home under the new NCQA standards. In spite of this fact, however, there is ample evidence that the availability of primary care is crucial to quality health care outcome, and more efficient care. The irony is that primary care is rapidly disappearing from the health care scene, since it not not nurtured and properly paid for.

There is widespread agreement that primary care is in crisis. Medical students often do not choose to practice primary care medicine. Existing doctors are often overwhelmed and patients aren't satisfied. Insurers say they are disappointed with its cost and quality.

The Patient Centered Medical home provides a way to change the status quo by enabling physicians to provide comprehensive primary care through stronger partnerships with their patients. Those that choose to integrate elements of this new model into their practices now have a mechanism to prove this distinction to patients and insurers. In order for these enhanced services to be sustainable, however, this designation must be recognized and rewarded by payers.

I ask all insurers to quickly develop products that support this effort. The time is now. We do not need another set of expectations for primary care physicians that are unfunded.