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Does Primary Care Need To Be Retooled?

Joe Cantlupe, for HealthLeaders Media, March 14, 2013

The president of Partners Healthcare and a Harvard University economist contend that primary care in the U.S. needs to be restructured to improve physician business practices and provide more value for patients.Under this "subgroup management," primary care physicians would oversee improved coordination of care for greater efficiencies and clinical outcomes.

So say Thomas H. Lee, MD, network president of Partners Healthcare, and Michael E. Porter, PhD, the Bishop William Lawrence University Professor at the Harvard Business School, and director of The Institute for Strategy and Competitiveness, both in Boston, in a Health Affairs article this month. I spoke to both of them about their primary care challenge. (Erika Pabo, MD, MBA, a resident at Brigham and Women's Hospital in Boston, was a co-author.)

"If we're going to make primary care as effective as we want to, we have to start with a clear overreaching goal and try to restructure primary care," Porter says. "It starts with value and that's the true north compass. Primary care isn't really one thing. It's a lot of different things for a lot of different patients with very different needs."

"If we can segment the needs and take patients and group them into fairly straightforward categories, such as healthy adults, or someone with one or two chronic conditions or very disabled people, we can understand the needs of a defined group of patients, and change the nature of primary care," Porter adds.

The primary care framework isn't working now, they say. As Lee sees it, too many physicians are "stumbling down a road, not sure where they are trying to go, as opposed to a bunch of people effectively moving down a road." For doctors, it's a vital question: their livelihoods are at stake.

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1 comments on "Does Primary Care Need To Be Retooled?"


George Anstadt MD FACOEM FACPM (3/14/2013 at 9:37 PM)
The Lee /Potter proposal: subjugate primary care physicians, and the patient's interests that the primary guards, using "market share" mechanism coupled with a "Strategic Frameworks" panacea; specialists and the system know best, or will know best as soon as Lee can assign someone the task of value guru. Further fractionate and specialize. The system with the most specialist wins. The patient centered notion is wrongheaded. In fact, as you look for value in the real world, the nations with the highest ratios of primary to specialty care are the best. For example, it is widely recognized that the US does 10x greater spine surgery than other nations, without any observed benefit in terms of spine health, but at far greater cost. No health status benefit / very high spine surgeon incomes + hospital charges + device prices = poor value. Lee contends that no one in his system is focused on health care value; yet, the primary is trained to provide value, which is best achieved by preventing disease in the first place, and also by finding simple solutions rather than tertiary care for problems. The US healthcare system impedes good primary care, especially prevention, with both financial disincentives and procedural barriers; never-the-less, if Dr. Lee were to examine the outcomes of his primary care doctors at the individual physician level, he would find a dedicated and caring minority who still do the right things, despite the difficulties, and as a result are getting much better health status outcomes, e.g. fewer MI, less new onset diabetes, etc., which save our healthcare system huge amounts of money. These are the overlooked folks in his system who are trained to provide value, and who ARE providing value. He should identify them, celebrate the increased health and decreased cost (value) that they are providing to our healthcare system, reward them financially, and learn from them. Their best practices should be facilitated with administrative and technology investments, and then shared them with the other primary care providers, which will not be a hard sell. Most of these primary care docs are longing to do these right things, but need encouragement, tools, time and financial incentives. Trouble is, insurance doesn't reward value, only encounters and procedures. So, Lee will have to figure out how to get paid for value, or just keep hiring more guys who do high revenue procedures, and push his primary care docs to encounter more people per hour. Our medical students are watching. Do we want more spine specialists and even fewer primary care docs?