Revitalizing Primary Care Said Key to Success of Health Reform
Employers have grown frustrated with buying health care in which no one seems to be accountable for patients’ overall health care needs.
For America’s employers, whether in the public sector or the private sector, health care is a problem.
And while the movement toward integrated, collaborative care is being driven by many forces, there is no doubt that the nation’s employers have been crucial, with a critical interest in the so-called “triple aim” of health care reform: improving quality of and patient satisfaction with care, improving the overall health of populations, and reducing the per capita cost of health care.
“Since the 1980s, health care has become the biggest challenge for employers,” psychiatrist David Nace, M.D., vice president for clinical development at the McKesson Corp., a health care services and information technology company, told Psychiatric News. “Employees are a company’s most valuable asset—if it doesn’t have a healthy workforce, it doesn’t have a productive company. But for the past 30 years, health care costs have grown at a faster rate than inflation. Very recently the rate of that rise appears to be slowing down—and that’s good news—but health care continues to be a huge proportion of employer costs and an enormous concern. And employers have become increasingly frustrated and tired of buying high-cost, frequently low-quality health care that is poorly coordinated.”
That problem led some member companies of the ERISA Industry Committee (ERIC, an association representing self-insured companies) to form in 2006 the Patient-Centered Primary Care Collaborative (PCPCC), a broad-based coalition of large and small employers, primary and specialty care medical groups, clinicians, health system administrators, patient and family advocacy groups, and other stakeholders dedicated to advancing an effective and efficient health system built on a strong foundation of primary care.
Personal physician: Each patient has an ongoing relationship with a personal physician trained to provide first contact and continuous and comprehensive care.
Physician-directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole-person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, as well as acute care, chronic care, and preventive services.
Coordinated and/or integrated care: Care is coordinated or integrated across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (for example, family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Quality and safety: Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care-planning process driven by a compassionate, robust partnership between physicians, patients, and their families. Evidence-based medicine and clinical decision-support tools guide decision making. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. Patients actively participate in decision making, and feedback is sought to ensure patients’ expectations are being met. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
These are the principles of the patient-centered medical home, adopted by the American Academy of Pediatrics, American Academy of Family Physicians, American Osteopathic Association, and American College of Physicians. The four groups have representatives who are permanent members of the board of directors of the Patient-Centered Primary Care Collaborative; APA is an executive level member.
Nace, who is chair of the PCPCC Board of Directors, said that the collaborative is regarded as the leading advocate of the “patient-centered medical home”—a concept that is central to the Affordable Care Act and to integrated, collaborative care that includes behavioral health. Four primary care specialty groups—the American Academy of Family Physicians, American Academy of Pediatrics, American Osteopathic Association, and American College of Physicians—formulated the principles of the patient-centered medical home in 2007.
Nace said that the motivating purpose behind the PCPCC is the need for a retooled health care system built around a revitalized model of primary care. “Primary care has been marginalized in this country,” Nace said. “If you think about the average family medicine doc—he or she sees patients with diabetes, congestive heart disease, depression, and substance abuse.
“Can you imagine having seven minutes to manage such a patient? But that’s what has happened to primary care in a fee-for-service environment—primary care physicians have a short amount of time to do something, but no real time to take care of patients. Certainly, there are pockets of excellence in our health care system, including outstanding psychiatric hospitals, but even in those centers of excellence, the care tends to be uncoordinated outside the hospital, with patients left to fend for themselves to navigate the system.
“Meanwhile, employers have gotten tired of buying health care in which no one seems to be accountable for taking care of patients’ overall needs,” Nace said. “We need a new kind of primary care, built around the patient-centered medical home.”
The collaborative achieves its mission through the work of five Stakeholder Centers. The centers are targeted to specific audiences and are dedicated to advancing primary care and the patient-centered medical home among policymakers, health care professionals, employers, researchers, and consumers. Each center is led by a volunteer committee of experts and thought leaders from PCPCC’s Executive Committee.
The Stakeholder Centers are Advocacy and Public Policy; Care Delivery and Integration; Employers and Purchasers; Outcomes and Evaluation; and Patients, Families, and Consumers. There are also four task forces formed around special interests: education and training, e-health, medication management, and behavioral health.
The last has been of special interest to Nace during his tenure as board chair. “Very early on in the development of the PCPCC, it became clear that a huge problem and one of the biggest challenges in health care is the comorbidity of mental health and substance abuse problems with general medical conditions,” he said.
The Behavioral Health Task Force provides networking and educational opportunities, including expert discussions, around the integration of behavioral health within the medical home. The group has also developed screening tools to help practices identify potential Medicare reimbursements and a list of resources on behavioral health integration including information about reimbursement for depression screening, reimbursement for screening and brief counseling interventions for alcohol misuse, and a comprehensive list of partner resources on behavioral health.
Nace says participation in the collaborative is free for individual clinicians, and he urges APA members to join. The Behavioral Health Task Force has monthly conference calls open to the public at noon EST on the third Wednesday of each month.
When asked how psychiatrists can catch the fast-moving train of integrated care, Nace repeats what other leaders in the field have said: get educated and get engaged. “Clinicians need to learn about collaborative care models and reach out to primary care practices wherever they are,” he said. “When I meet with primary care physician practices, I hear time and time again that they are frustrated with patients who present with depression, anxiety, and substance abuse, and they don’t know what to do. They frequently can’t find someone to refer them to, so they prescribe the meds the drug companies provide, because they only have seven minutes to spend with the patient.
“We are in a remarkable period of transformation in American health care, and there will be winners and losers,” Nace said. “The winners will be people who step up and work with others. The transformation will happen locally and will be based on building relationships.” ■
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Published online: 7 March 2014
Published in print: February 22, 2014 – March 7, 2014
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