The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be "preferentially" scheduled to facilitate more efficient visits that may include group educational programs, they write.
Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.
It's no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. "Various organizations have built a whole care model for those people," Porter says.
He pointed out some examples, including the Commonwealth Care Alliance , which includes multidisciplinary teams and home visits. Others having integrated delivery care, where primary care and specialists work hand-in-hand, include CareMore, Intermountain Healthcare, Cherokee Health System, and the Department of Veterans Affairs.
To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a "total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients."
While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. "We've got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero," Lee says of Partners. "It's not anyone's job right now. Therefore, no one does it in a systematic way."