Advanced Primary Care

Michael Thompson: I want to explore 2 trends that we are certainly supporting at the National Alliance of Healthcare Purchaser Coalitions, but I want to hear your views on this. One of them is putting more emphasis on advanced primary care. Why primary care? Why is that a winning strategy? Would you have concerns going in that direction?

Andrew Crighton, MD: No. I think if you look at other countries, where medical costs are well in check, they have a higher percentage of primary care. That’s kind of the quarterback, the conductor of the orchestra, when someone needs coordination through the healthcare system. The primary care physician is prime and ready to do this, but they’ve got to be rewarded. They have to have the time to help someone navigate and advocate.

Michael Thompson: Yeah. Bruce?

Bruce Sherman, MD: There’s a sense of connectedness. There was a study in a medical journal, probably 10 years ago, about this notion of connectedness. When the provider was able to connect with the patient, compliance with care was much better, and the clinical outcomes were much better. I’ve also seen that there was a greater level of satisfaction—for the patient and the provider.

We know from other studies that effective use of primary care at a population level results in substantially lower overall healthcare costs for individuals who are engaged. So there’s a compelling business case.

Michael Thompson: That is a bright spot we’ve seen in the last 15 years in some of these emerging models—on-site clinics, near-site clinics, and sometimes building new clinics in communities. Frankly, we’ve had some concern as primary care has gotten bought by health systems. Their orientation is not the same as advanced primary care. In fact, have you seen anything like that, in terms of any issues?

Andrew Crighton, MD: We do see more churning, so that relationship with the patient is less likely to happen. You may not see the same provider the next time you go to this group, so you haven’t developed the trust. Are you going to follow through on the recommendation? There needs to be a relationship. Second, it’s easier to refer to a specialist. Rather than taking care of the issue and trying to address it, it’s like, “I have 7 minutes. I’m going to just send you to the gastroenterologist.”

Bruce Sherman, MD: There’s an important point to be made here about employers that are opting for third-party entities, like on-site clinics or near-site clinics. It seems easier for the employers to disrupt the system—by contracting with an outside third party, which has no concern or much less concern about a potential conflict of interest. Andy, are those primary care practitioners, owned by or salaried by the healthcare system, incentivized somehow, subtly or not, to refer internally for additional testing and services as opposed to a self-contained group?

Michael Thompson: I’ve heard war stories, where great primary care operated within a health system gets toned down, in part because it’s reducing emergency room visits and admissions, and that’s not consistent with the business model. We must look at values—if that’s what we’re about. If we can truly improve the health of our population, then why wouldn’t we operate with that?

Pat, you mentioned before that we’re not going to get great primary care if we keep treating primary care the same way we do today.

Patricia Haines: Right. I strongly believe that they have these limited periods of time, and there aren’t enough of them. I think they’re not choosing it because they’re not rewarded appropriately.

Michael Thompson: I think there are new emerging business models to help make that happen. Part of that is physician extenders and team-based care, which allows primary care to use the professionals at the top of their profession.

Patricia Haines: How about the impact of urgent care and telemedicine? We’re seeing a very high use of telemedicine. I think that’s good but maybe not so good. Good because it really meets a need, and not so good because it may in fact damage the relationship with primary care. Seventy-five percent of our telemedicine events have resulted in a prescription, and I’m not always sure that’s the answer. That’s a quick answer, and it’s an easy answer telephonically, but I’m curious about how our physicians feel around this.

Bruce Sherman, MD: I absolutely agree with you. We’re just starting to look at some data to understand if the telehealth that’s being used is a function of third-party entities that contract with the health plans to provide telehealth services. Or is it integrated delivery networks and health systems that have telemedicine capabilities? We’re still learning what services and what proportion of those services are being used by which individuals, because you have the potential for further fragmentation of care delivery. Retail clinics are another potential risk of that happening. But if there is effective communication with the primary care practices, then it may be less of a concern.

The other issue is, are we creating or inducing demand, by virtue of making access to healthcare easier through telehealth? Some of the early studies of telemedicine would suggest that at least some of that may be happening.

Andrew Crighton, MD: As you talk about urgent care, it’s creeping in to the chronic care type of thing. It’s become episodic. You may not see the same provider all the time. Electronic medical records are the hardest thing to navigate—from a provider’s standpoint—to find out what that provider was thinking when they were making a decision. We’re kind of losing some things in communication—things are being done over and over again. The episodic care that we give, as Bruce said, makes it easier access but not necessarily appropriate access.