It’s time to talk about the primary care infrastructure

By Bruce Bagley, M.D.
TransforMED CEO

Let’s face it, we have made tremendous progress over the past few years in defining and implementing the patient-centered medical home. Practices throughout the country have been recognized by NCQA and others for their achievement but resources and payments have been slow to change in a system that is mired in the fee-for-service mode. Even in some of our best blended payment models, the proportion of payment to support the infrastructure required is inadequate for what we are expected to accomplish for patients.

In the past, we have seen integrated delivery systems or hospitals make huge capital investments in the cardiology wing or the cancer wing. They have installed all the expensive equipment required so that the cardiologists or the oncologists could offer the latest and greatest treatment to patients with those ailments. There is a required infrastructure to do this work well and the investment was well worth it to the system because it assured a revenue stream from that service line.

Whether primary care practices are independent or affiliated with a larger system, they all need a level of infrastructure support that extends from facilities and equipment to care coordinators and health coaches. In the past, support for such things had to come from fee for service revenue resulting almost exclusively from face-to-face visits. It is time to rethink what it takes to support optimal primary care so that wellness, preventive services, chronic illness care, and acute patient care are optimized.

What are the essential elements of the required infrastructure for primary care clinicians to do their best work? How should we pay for that infrastructure? Who will build the proverbial “primary care wing” to assure a revenue stream from that service line? These are critical questions we need to answer if we are to fulfill the promise of the patient-centered medical home to our patients and to our nation’s health system.

Electronic medical records and connectivity
Although nearly 80 percent of primary care practices now have some form of EMR, many of these systems are clunky and impede rather than enhance the workflow. Information technology must support the core business, clinical, and communication functions of the primary care office. Embedded protocols and reminders, decision support functions, point of care registries, patient portals, and support for patient outreach must be part of the normal workflow and the shared responsibility of all the care team members. Efficient entry of clinical data and office notes remains a challenge for many clinicians. Primary care physicians need a system that works for them and enhances their ability to care for patients in a team environment.

Complete and timely data for improvement and to document quality
All too often the conversation about quality metric is translated into the idea that it is an extra and unnecessary burden imposed on the clinicians by the payers. With systems in place such as registries for chronic illness care, all the clinical parameters that the physician would want to see to make the best decision and recommendations for a patient are collected, organized, and displayed in a way that is useful and efficient. Care team members all have a role and responsibility in making sure that the clinical information is complete, gaps in evidence-based care are identified, and action is taken to close those gaps. Primary care practices need to have near real-time data feedback to continually improve service, cost, and quality. Ideally this is built in to the system of care and not an additional task.

Support for patient engagement and team care
In the past there have been very few resources available for patient self-management support or a team approach to helping patients do better in managing their own care and wellness. Part of the essential infrastructure is to supply sufficient time, energy, and people in roles such as health coaching, population management, social work, home care, and home monitoring. Care teams can be trained to help with informed medical decision making, motivational interviewing, shared goal setting, and between-visit follow up. It is now clear that these efforts result in better outcomes for patients and lower costs for the health care system.

Positive, efficient, and effective interactions with specialty services
Primary care cannot provide value for patients without efficient access to the rest of the medical neighborhood. Comprehensive primary care should be able to provide most of the care for the common everyday needs of patients but also must take on the responsibility of helping to procure other services from the community that are timely, high quality, properly priced, and service oriented. This is clearly a two-way street with good communications in both directions. Creating a sense of shared responsibility for service, cost, and quality is everyone’s job. Referral guidelines, service agreements, and regular interchange about shared roles and responsibilities that are all focused on the best possible outcomes for patients must be the new norm.

Care management and care coordination within the neighborhood
Risk stratified care management and care coordination may be one of the highest leverage strategies for helping patients and saving money. Knowing which patients need extra time, effort, and guidance in navigating their illness and/or the complex health care system is the first step to appropriate resource allocation. Proactive intervention with high-risk patients has clearly been shown to give better results for patients and reduce ER visits and hospital admissions. Patients get better care at lower cost.

How should we pay for this infrastructure?
It is not realistic to expect this investment in infrastructure to come from fee revenue. That was never part of the consideration for the cardiologists or the oncologists when planning for the “new wing.” The emergence of a care management fee has provided one way to think about supporting these additional services that may or may not be associated with a visit to the office. To date, most of the care management fees have not been adequate to support the changes required or have been for only a small portion of the patients in the practice and therefore not enough total resources to support these new services. In the case of integrated or consolidated systems, they can and should direct the resources to support primary care infrastructure as part of their strategy to succeed in a value based purchasing environment. In essence, they should build the community capacity for capable primary care... “the primary care wing.” That capital investment should assure a revenue stream from that service line to the organization.

Bruce Bagley, M.D., F.A.A.F.P., is president and CEO of TransforMED, a wholly owned subsidiary of the American Academy of Family Physicians. This article appears in Texas Family Physician with permission, and was originally published as the final 2013 installment of “Report from the CEO” on the TransforMED website, www.transformed.com.