We need to reset primary care

According to a recent WSJ article, one in four Americans lives with more than one chronic illness; three out of four among those 65 and older. That author goes on to recommend how patients with multiple chronic illnesses and their family members can help doctors by coming to appointments with prepared lists?of medications and documentation of recent changes in their condition.?

The approach to the 5% of the sickest patients accounting for 50% of US sick care spending has been disease management programs. Unfortunately, they don't reduce the costs and a recent article in the Harvard Business Review explains why. The 5% are not homogeneous, but rather consist of three groups: 1)a third with multiple ,chronic complex conditions, which, if managed, can prevent premature progression or unnecessary ER visits or hospitalizations, 2) a third who experience a onetime catastrophic health event, most of which are unpredictable, and 3) a third with diseases like renal or heart failure who require expensive ongoing treatment. Leveraged primary care is designed to treat the first cohort with better outcomes at less cost.

The primary care business model is on life support. Millennials don't want to wait for an appointment to treat their cold that isn't getting better. Approximately 80% of internal medicine residents, including nearly two-thirds of those who specifically chose primary care tracks,?do not plan to pursue careers in primary care.

Value based care is gradually displacing fee for service care. Kinderhook Industries, an investment firm, has provided a $500 million investment in Physician Partners, a primary care physician group and managed service organization in Florida.?Physician Partners serves more than 137,000 members with more than 545 physicians. It partners with national and regional Medicare Advantage health plans in the state. Physician Partners aims to disrupt traditional healthcare through value-based care. The investment will accelerate the network’s next phase of growth

CVS Health Corp. executives will lean on both acquisitions and partnerships to expand the scope of its primary care offerings in coming years to include care coordination and mental health services.

Speaking to analysts and investors Dec. 9, CVS CEO Karen Lynch and her top lieutenants laid out their vison for the Woonsocket, Rhode Island-based company’s evolution, which calls for profit growth to accelerate in the middle of the decade as investments begin to pay off. A key element, Lynch said, is growing primary care, which accounts for about 10 percent of U.S. health care spending but can drive extensive use of other parts of the system.

Staffing shortages among healthcare providers are having numerous downstream effects on everything from patient care to?reimbursement?and thinning margins. But they're also causing a shift in public perception: More people now trust pharmacists to play a larger role in their care management, according to new research from Columbia University Mailman School of Public Health in New York City and Express Scripts Pharmacy.

The world seems to be getting ever more complicated and the same holds true of patients as the average life span increases. Expecting primary care physicians to take care of more and more complicated patients in less and less time is an unrealistic expectation and the suggestions made in the article places an unrealistic expectation on patients as well. But, there is more:

1. PCPs are expected to do not just chronic care management, but acute care, complex chronic care, population health management, cost-effective analysis, behavioral?heath, gun safety counseling, social systems impact on health?and much more. However, with care navigators, educators and coaches using apps, is the doctor the right person to deliver chronic disease management or just supervise it?

2. Most doctors lack the interest, knowledge, skills or time to do everything

3. Lack of continuity of care, increasing siloing of care and poor interoperability of medicine records contributes to islands of information that are not connected

4. Care teams are usually not structured properly and their size is increasing with non-MD participants.

5. Interprofessional communication fails

6. Inpatient information is not connected to outpatient information

7. More and more digital health information and IoT information is disconnected from the medical record

8. Doctors are drowning in big data instead of actionable information

9. Many times the data or information is wrong and is responsible for medical errors.

10. There are not enough data scientists, care navigators, infomediaries and people in yet to be described jobs to manage all the complex care responsibilities.

When taking care of patients with complex illnesses, it is increasingly inefficient for one doctor to take care of one patient. Instead, the patient's team, including caregivers, relatives, surrogates and personal representatives are the ones doing the heavy lifting and communications need to be directed to them if not more than to the patient. There are other obstacles to chronic, complex care:

• Doctors’ views of practice preparedness to manage the care of these patients decline steeply when patients have severe mental illness or substance abuse-related problems.
• Primary care practice capacity to provide enhanced access and care management depend heavily on the use of allied health professionals and technology solutions, such as email access and patient portals.
• Primary care physicians’ ability to coordinate care for these patients is hampered by lack of communication with specialists, hospitals and emergency departments, home care providers, and social services organizations.
• Uptake of electronic medical records (EMRs) has been steep over the past three years, especially in Canada and the United States, but interoperability remains a significant challenge.
• The primary care business model is not profitable

Major retailers?are extending their reach deeper into the care continuum, and it has major implications for how and where care is delivered and paid for as well as by whom.?CVS, Walgreens, Walmart, and?tech giant Amazon are ramping up their focus on providing medical services to gain bigger footholds in the healthcare market.?These "nontraditional players" are gaining traction and have the potential to grab as much as 30% of the $260 billion U.S. primary care market by 2030, according to a recent?report?from Bain & Company.

?In addition, it may be time to give the slip to the SOAP note. While useful in organizing information, it does not prioritize problems by levels of complexity or prioritize the information needed to help manage them. The idea behind the H&P 360 is that by including at least a few questions in each of six domains besides the traditional biomedical information in the routine history, physicians’ care of patients will improve.

Those additional domains are:

• Patients’ perceptions of health, goals and values.
• Mental health conditions.
• Behavioral health.
• Social support.
• Environmental or physical resources.
• Function.

We need?to unbundle how the work of sick care gets done and re-engineer the processes. For example, should primary care doctors do health screening or should pharmacists? Should PCPs be expected to make sense of BIG DATA, or should we train a cohort of clinical data scientists and clinical data managers to help doctors and patients sort through the mess? Should specialists take care of more complex problems or should they continue to be high priced primary care doctors as a large percentage of their practice?

Over the last 5 years. several companies have seized the opportunity.

Here are some other ways to re-engineer primary care processes and systems. As described,?it’s backwards to think that the solution to the primary care problem is for patients spend more time with primary care providers.

Three places to start are reform the payment model, fix EHR technology, and change medical education.

In addition, we need more research to determine what works and what does not in the primary care setting. The majority of patients in the U.S. get treated in primary care settings, yet a?new analysis?finds that a major federal research program only funds a minority of studies focused on primary care.

Taking care of patients with chronic, complex care means more than being sure they have insurance. Instead, it involves merging social, behavioral, financial and sick care needs and creating new models and using new tools to do it.

A new crop of healthcare startups are trying to shake up the $260 billion primary care market. In addition, BIG TECH, cable and telecommunications companies are changing the care models and distribution channels.

The first step will be in changing the rules and reimbursement, changing the organization of care teams and educating patients that one doctor can't do all things for all patients.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@SoPEOfficial and Co-editor of Digital Health Entrepreneurship

This work is licensed under a?Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Updated 11/2022