Perhaps increasing access to primary care needs a new approach – rewarding evidenced based care, rather than outpatient visits.

Some highly acclaimed initiatives to improve access to quality primary health care and reduce cost have proved challenging. Over the past several weeks we have seen several glaring examples –  hospitals leaving ACOs, no change in ED use, the uphill strategy to train more primary care physicians, and “whatever happened” to medical homes. 

Dartmouth was the national leader in establishing an Accountable Care Organization. “Why Accountable Care? The current health care system, which pays for discrete medical services instead of outcomes, has resulted in fragmented care and fueled enormous growth in health care costs. To create a more sustainable system, we need a new model that holds health systems and providers accountable for the quality of care delivered to patients. By promoting strategic integration and rewards based on quality care, the Accountable Care Organization (ACO) model offers a potential win-win for providers, payers and patients alike.” (A)

The Dartmouth Atlas quickly became the ACO “bible.” “Under the program, primary care physicians are encouraged to join together with other providers to take responsibility for the full continuum of their primary care patients’ care. They must commit to reporting comprehensive measures of the quality and — eventually — outcomes of care. If they are able to improve quality and thereby reduce costs, they will receive a share of the savings achieved. The term “accountable” is intended to mean just that; ACOs should only receive additional payments to the extent that they are demonstrably improving care for their patients.” (B)

Now: “Dartmouth-Hitchcock Medical Center will abandon the Pioneer Accountable Care Organization program, the system confirmed Tuesday, after losing more than $3 million over the past two years in the Centers for Medicare and Medicaid model.” (C)

“Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care? Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine. The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors’ offices.” (D) “People covered by Medicaid were more likely to both see a physician at a regular office visit and also go to the emergency room, casting doubt on the idea that people were using health coverage to shift their health care to a primary care doctor.” (E)

“One “hidden” benefit of the Affordable Care Act is its potential to make primary care more accessible. The U.S. has long lagged behind other industrialized countries on primary care—at great cost to our health and our economy. Throughout the legislation are provisions that, if considered together and implemented effectively, will strengthen primary care for all Americans. With stronger primary care, people will be more likely to receive recommended preventive care and timely care for medical problems before they become serious and more costly to treat.” (F)

Well over twenty new medical schools have opened in the last ten years with more in the pipeline. “Many of the schools under development are making a bigger push to educate future primary care physicians, which will be in greater need to improve the quality of medical care and lower costs by keeping patients out of the more expensive hospital setting.” (G)

But in 2013 AARP reported: “Today, the United States is short about 16,000 primary care doctors — the very doctors (family practitioners, internists and pediatricians) who offer the treatments and preventive screenings that save lives and head off expensive emergency room visits and hospitalizations. Why the shortage? It starts with huge medical school debts and ends with a doctor who is often overworked and underpaid. While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that. Only one in five graduating internal medicine residents plans to go into primary care medicine……” (H)

“The number of primary care physicians is projected to increase from 205,000 FTEs in 2010 to 220,800 FTEs in 2020, an 8-percent increase. The total demand for primary care physicians is projected to grow by 28,700, from 212,500 FTEs in 2010 to 241,200 FTEs in 2020, a 14-percent increase. Without changes to how primary care is delivered, the growth in primary care physician supply will not be adequate to meet demand in 2020, with a projected shortage of 20,400physicians. While this deficit is not as large as has been found in prior studies, the projected shortage of primary care physicians is still significant.” (I)

The “medical home” was the moon shot to improve access to primary care. “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.” (J) “Medical home” has fallen off the innovation radar.

Some extreme, perhaps patient “unfriendly,” options to think about:

VALUE BASED INSURANCE. “The additional cost when patients choose procedures that research shows are unlikely to help their condition is a key element of ….value-based insurance, the premise of which is that a mix of financial carrots and sticks can steer patients toward medical services that will help them and away from ineffective or unnecessary ones.” (K)

REFERENCE PRICING.  “Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder. This has the remarkable feature of exposing the patient to the variation in prices for treatments that are above deductible thresholds. And the patient’s contribution isn’t limited by an annual out-of-pocket maximum. “(L)

Perhaps we can do better! by rewarding evidenced based care, rather than outpatient visits.

 

 

 

(A)      http://tdi.dartmouth.edu/research/evaluating/health-system-focus/accountable-care-organizations

(B)      http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2943

(C)      http://www.healthcarefinancenews.com/news/dartmouth-hitchcock-exit-pioneer-aco-program-over-losses-calls-model-%E2%80%98unsustainable%E2%80%99

(D)      http://www.npr.org/sections/health-shots/2016/10/19/498526110/emergency-room-use-stays-high-in-oregon-medicaid-study

(E)       https://www.washingtonpost.com/news/wonk/wp/2016/10/19/more-evidence-expanding-medicaid-increases-emergency-room-visits/

(F)       http://www.commonwealthfund.org/publications/blog/2011/jan/affordable-care-act-bolsters-primary-care

(G)      http://www.forbes.com/sites/brucejapsen/2012/07/17/as-obamacare-looms-new-medical-schools-open-to-address-doctor-shortage/#ee36f65767ca

(H)      http://www.aarp.org/health/medicare-insurance/info-03-2013/how-to-beat-doctor-shortage.html

(I)        http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/

(J)       https://www.pcpcc.org/about/medical-home

(K)      http://www.reuters.com/article/us-usa-healthcare-insurance-idUSBRE9BI04X20131219

(L)       http://www.wsj.com/news/articles/SB10001424052702303448104579152111004814066

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