The problem of insufficient supply of primary care physicians has been with us for more than a decade. Yet the availability of primary care is a prerequisite for health reform’s success, particularly in its evolved form—the patient-centered medical home.
Not every generalist’s practice qualifies as a “medical home,” the centerpiece of access to primary care for the millions of people who will be newly covered once health reform is implemented. The medical home is supposed to be able to manage each person’s care on a continuous basis, serving as the coordination center for specialists and healthcare services. What does it take to be a medical home? First, it means fulfilling a set of standards. Second, it means actually having patients who utilize the practice as their coordinated care center.
A study from the University of Michigan Health System found that approximately 46% of medical practices do not meet the standards (set by the National Committee for Quality Assurance) for a medical home (Hollingsworth JM, Saint S, Sakshaug JW, Hayward RA, Zhang L, Miller DC. Physician practices and readiness for medical home reforms: policy, pitfalls, and possibilities. Health Serv Res Oct 18 2011 DOI: 10.1111/j.1475-6773.2011.01332.x). According to the Committee, a patient-centered medical home is “a model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has a relationship with a primary care clinician who leads a team that takes collective responsibility for patient care.” (http://www.ncqa.org/LinkClick.aspx?fileticket=ycS4coFOGnw%3d&tabid=631
) This is achieved by a combination of accessibility to the physician, enhanced communication among clinicians and staff, and the use of information technology.
This doesn’t sound mysterious or necessarily difficult to attain, especially with the current push for electronic medical records, but apparently it is not so easy to meet the standards. According to the study, 72% of multispecialty groups were recognized as fulfilling the criteria as medical homes, compared with only 50% of solo or small groups. This makes sense, as the larger multispecialty groups generally spend money on infrastructure (and have more dollars to spend) than smaller practices. Only 40% of primary care practices today would qualify as medical homes; this is disheartening, because family physicians, general practitioners, obstetrician/gynecologists, and other clinicians were long considered by managed care organizations to play a special role in patient care and cost containment through their coordination efforts. Whether they were considered “gatekeepers” in the 1980s or “primary care physicians” in the 1990s, the general idea was that these clinicians would refer patients for needed specialist care or diagnostic imaging in order to efficiently care for the needs of patients, especially those with chronic illnesses.
The simple truth is that without electronic medical or health records, this is too great a challenge. Many practices are still paper-based. Today, very few patients will witness their family physician walk into an exam room with an iPad fully connected to the practice’s server, showing the patient’s comprehensive medical history and diagnostic imaging results, with available icons for professional society practice guidelines and the drug formulary for that patient’s particular health plan. However, the incentives contained in the 2010 Patient Protection and Affordable Care Act (PPACA) attempts to build more medical home capacity ahead of the influx of 15.8 million Americans newly eligible for coverage in 2014, and up to 30.6 million in 2019.(Sisko AM, Truffer CJ, Keehan SP, et al. National health spending projections: The estimated impact of reform through 2019. Health Aff.
2010;29:1933-1941.) The incentives generally consist of higher reimbursements for practices recognized as meeting the standards for medical homes and federal help in installing electronic medical records.
The authors of the study suggest that legislative incentives might be better aimed at merging small and solo physician practices into larger groups, which may be better able to meet the criteria for medical homes (if they don’t already meet the criteria) and facilitate the growth of medical home capacity. This may be a more realistic way to increase the number of clinicians available to work in medical homes, but it does little to solve the underlying primary care shortage, especially in geographic areas already suffering a drought of primary care talent. This will only pay off if there is increased pay, more attractive work environments, and better programs for nurse practitioners and physician assistants.