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Will Primary Care Be Re-Empowered by an Ailing Economy?

Richard L. Reece, MD, and Brian Klepper, PhD, September 25, 2008

Staff physicians win as well, often making one-third or more than doctors in private practice, with the luxury of spending more time with patients and, because no money changes hand, focusing on care and not worrying about the practice's business aspects.

The clinicians use a complete complement of informational tools: claims analytics and health risk appraisals to identify patients at risk, electronic medical records with embedded best practice and care gap guidelines, and provider profiles to steer patients needing referrals to high performance specialists and inpatient facilities.

Worksite clinics can have had tremendous impact. The City of Port St. Lucie, FL, reported a 3.1:1 return on investment and an 18% total health plan cost drop in its first year of operations. Returns on occupational health, retention and recruitment and lost productivity, are harder to quantify but probably even higher.

Transforming community primary care practices

Worksite clinics are fine for patients in corporations, but how do we change the thousands of small and mid-sized primary care practices in the field? More importantly, how do we allow them to perform the full range of cognitive medicine services they're capable of? Finally, how do we make it worth their while, get primary care off the gerbil's wheel, and encourage young doctors to become generalists?

Two years ago, Paul Grundy, MD, MPH, IBM's Director of Health Transformation, became concerned that his company could not buy comprehensive coordinated care for its U.S. employees.

He could buy an amputation of a diabetic's leg, but he could not buy prevention services to avoid that amputation. Often, he did not see "value" in the outcomes or patient satisfaction associated with the episodic care that IBM was purchasing. He also worried that many of his employees could not name their personal physicians. He saw American primary care's very existence threatened. He knew from a literature review and from IBM's Denmark experience that primary care-based systems saved about 20% in costs and produced 30% better results with immensely greater satisfaction among patients and physicians.

Grundy and his colleagues act

Working through a multi-constituency, action-oriented organization, the Patient Centered Primary Care Collaborative, Dr. Grundy and his colleagues began to drive a powerful market-based reform initiative.

They assembled leaders of nearly 50 Fortune organizations and seven major health plans to describe their findings. His advice to the plans was to move quickly to a primary care model or risk public confrontation and isolation by the Fortunes.

He gathered medical society representatives-family physicians, internists, pediatricians, and osteopaths-for recommendations to re-empower primary care. The result was a declaration of Joint Principles of a Medical Home. Effectively, they argue that American healthcare can be dramatically improved and its cost crisis largely ameliorated if:

  • Primary care physicians are paid more to collaborate with specialists on the full continuum management of their patients. This would also reduce the profound income gap between primary care and specialist physicians, and provide reason for medical students to again enter primary care as a career.
  • Mechanisms can be developed to ensure that primary care physicians have access to the full range of modern patient evaluation and management information technology tools.
  • The rules of engagement are changed between primary care physicians and specialists, so that they can more easily collaborate on patients' care.

This is not a lone view. MEDPAC, the Medicare Payment Commission has also urged Medicare to use medical homes to get Medicare costs under control. In 26 state legislatures, 108 bills introduce "medical homes," and 20 bills in 10 states define the concept and provide for demonstration projects. A few innovative health systems around the country—the Geisinger Health System in Pennsylvania; the Holston Medical Group in Kingsport, TN; Alabama Medicaid; HealthPartners in Minnesota—are actively proving its value.

So far, the major health plans have mounted a few pilots, but nothing substantive or systemic has changed in the way that primary care physicians around the country treated by health plans or specialists. The jury's still out on whether they'll be willing to drive down total claims costs—remember they make a percentage of the whole—by taking advantage of primary care, the most powerful tool at their command.

What does this all mean? Business is defending and advancing its own best interests by taking an active, influential role in transforming healthcare. Whether it can bring enough pressure to bear to bring the entrenched healthcare industry along remains to be seen. But its cause may have just received a boost from the nation's economic woes.


Dr. Richard Reece is author of Innovation-Driven Healthcare: 34 Key Concepts for Transformation and is currently at work on a new book with Paul Grundy MD MPH called Primary Solution. He maintains a column at MedInnovation Blog.

Brian Klepper is a healthcare analyst, speaker and commentator whose consulting firm, Healthcare Performance, helps organization understand and negotiate market-based healthcare reforms that are gaining traction now.

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