How Primary Care Can Handle 15 Million Newly Insured Patients

People have always needed excellent primary care. And patients may fret about how the millions of uninsured people projected to sign up for coverage in 2014 will affect access to care. Here's what must happen.
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(Stefan Wermuth/Reuters)

As debate about Obamacare rages, some proportion of the 48 million uninsured Americans are gradually enrolling in health insurance, some for the first time in their lives. But then what? Will health care spending rise as a result of this coverage expansion? Are we just adding more people to the rolls of an already overburdened system?

Answering these questions requires focusing on the linchpin of the United States’ health system: primary care. Our concept of primary care is undergoing a historic reinvention. A principal driver of this metamorphosis is the inexorable rise in health care spending. Despite projections of slower cost growth in the coming decade, health spending will nevertheless total one-fifth of the nation’s GDP by 2022.

In response to the fiscal situation, both government and private insurers are driving a transformation from volume-based reimbursement (where payment is based on services rendered) to value-based purchasing (where payment is based on patient outcomes).

Take a diabetic patient, for instance: instead of paying separately for the requisite nutritional counseling, medication management, and eye exams, the insurer would pay for the entire spectrum of the patient’s care, with financial incentives tied to positive outcomes.

In value-based payment models, the importance of continuity—longitudinal relationships with patients—and coordination of care is heightened. For example, a study of more than 3 million Medicare beneficiaries showed that more primary care continuity was linked to fewer preventable hospitalizations. The primary care team’s responsibility as the “quarterback” for a patient’s health needs also becomes more significant. Respecting patients’ values and preferences, resolving conflicting opinions among specialists, and communicating with professional and family caregivers all fall within the purview of primary care.

Flowing from this foundation of continuity and coordination, a growing consensus is emerging around what the key elements of high-quality primary care should be:

Patient-centered medical home model with team-based care delivery

 The Joint Principles of the Patient-Centered Medical Home (PCMH) describe the delivery of comprehensive primary care by a physician-led team: an orientation around treating the whole person, integrated care, quality and safety monitoring, enhanced access, and value-based payment. The American College of Physicians recently endeavored to further define team-based care, advocating for a cooperative interprofessional approach involving doctors, nurses, physician assistants, pharmacists, and other health care professionals. In practice, the patient-centered medical home has begun to demonstrate modestly improved quality and cost results. For example, the CareFirst BlueCross Blueshield PCMH initiative, showed overall savings of 2.7 percent over two years—while improving global quality outcomes for the one million patients enrolled in the initiative.

Population health management with patient risk stratification 

Taking responsibility for population health means managing the health outcomes of a group of individuals. Often, one primary care team will be assigned to take care of a population of 1500 to 2000 patients. The startup Evolent Health seeks to blur the boundaries between insurers and health care providers by risk-stratifying these patient populations and customizing interventions to specific risks. Based on longitudinal health record data, a statistical model can reliably predict a patient’s risk for adverse outcomes, such as hospitalization. Appropriate care management services can then be tailored based on the patient’s risk.

High-risk patient management

 Nationally, just 10 percent of the population is estimated to account for about 64 percent of health care expenditures, often because of the overuse of hospital-based resources. By addressing care coordination, targeting intensive interventions, and ensuring greater clinic access, concentrating on this segment of the population improves their health while reducing costs. Many primary care practices are now testing methods of high-risk patient management, such as an “ambulatory intensive caring unit.” Preliminary evidence from programs for high-risk elderly patients shows modest reductions in hospital and emergency department use.

Integrated behavioral health

 Individuals with serious physical health problems often have concomitant mental health issues, and nearly half of those with any mental disorder meet the criteria for two or more disorders. However, most primary care doctors are ill-equipped or lack the time to fully address the psychosocial issues underlying many patients’ visits. A number of models for integrated or collaborative behavioral health and primary care are emerging. In one example, the Southcentral Foundation’s Nuka System of Care in Alaska normalizes behavioral health as a routine component of medical care, with integrated charts, care teams, and clinic design facilitating a spectrum of collaboration, from informal consultation to joint visits to more formal referrals.

Rapid, judicious access to specialty expertise

 Innovations in specialist access may help improve the value of costly specialty care while widening its reach. For instance, in San Francisco, a program known as eReferral—piloted in a safety-net system—uses simple technology to allow primary care providers to communicate quickly with specialists, sometimes eliminating the need for in-person consultation. In the same vein, a national program known as Project ECHO has shown that with the right staffing and technology infrastructure, primary care providers can co-manage patients with complex, chronic diseases like Hepatitis C.

Moving more care into the community and into the home

 For primary care to improve health on a large scale, it must extend beyond a clinic’s walls into patients’ communities. Community health workers—lay community members with focused health care training—enhance episodic primary care through continuous, personal partnerships. Meanwhile, home-based primary care, usually delivered by interdisciplinary teams, treats seriously ill patients whom routine clinic-based care is unable to accommodate. The Veterans Health Administration has pioneered home-based primary care programs that facilitate veterans’ independence at home, provide much-needed support to caregivers, and may avert costly hospital visits and nursing home stays.

I chose a career in primary care in part because of these inspiring bright spots. Startup primary care networks like Iora Health offer a chance to disrupt the existing health care paradigm. And investment by established institutions like Harvard Medical School (in a Center for Primary Care) and the American Medical Association (in innovative primary care training) indicates broader interest in improving primary care.

People have always needed excellent primary care. And patients may fret about how the 15 million uninsured people projected to sign up for coverage in 2014 will affect access to care. But grassroots groups like Primary Care Progress are branding this a once-in-a-generation opportunity to revitalize our health infrastructure, and healing our sick healthcare system starts with elevating high-quality primary care. 

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Dave Chokshi is a primary-care doctor. He recently served as a White House Fellow with the Department of Veterans Affairs.

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