There is a quiet, early revolution going on in medicine. We are beginning to redefine how we provide primary care, moving from a traditional “one on one” patient/doctor relationship to a new model which emphasizes a medical team providing patient focused care.
The name of this new model of care is usually referred to as a “patient centered medical home,” or some variation of those words. The impact of this change—which will take years to better define much less accomplish—has the potential to be enormous and transformational.
If done right, this effort has the potential to vastly improve the care we provide our patients, emphasizing prevention as well as more effective, evidence-based primary care medicine when someone develops an illness or a chronic medical condition such as diabetes or heart disease.
In my personal opinion, we have the most technologically advanced medical care system in the world. What we don’t have is the most effective medical care system, based on a variety of measures. We can provide excellent care, but there is no systematic way to evaluate what we do, there is no way to get needed preventive services to those who need them, and too many people have either no access to medical care, have inadequate access, or can’t afford to get the care they need.
Otis Brawley, MD—who is the American Cancer Society’s Chief Medical Officer—has a slide that he uses in his lectures on access to care which shows the average life expectancy in many countries around the world. Superimposed on this data is another line which shows the relative costs of medical care in those same countries.
What you see on that slide would probably startle many of you: Yes, there is a relationship between life span and the amount of money spent on medical care. In those countries that spend larger amounts, life expectancy is longer—with one glaring exception: the United States.
The countries with the longest life expectancy are on the left side of the graph. Down towards the right end of the same graph sits the United States. Yes, our life expectancy is significantly lower than many other countries on this planet. But the cost line goes way, way up for the United States—higher than any other country in the world.
We spend a whole lot of money providing medical care in this country, but our life expectancy is less than many others including some of which many would consider economically much poorer and much less developed than the United States.
Something simply doesn’t make sense. We spend money, but don’t improve the quality of care for our citizens or their quality of life, or the length of their years.
These aren’t new concerns, but there is now a growing realization that our medical care non-system is seriously overloaded with specialist physicians and grossly inadequate when it comes to having enough physicians and related health professionals providing primary care.
We know that having a relationship with a regular source of primary care leads to better outcomes. We know that where there are more specialists practicing medicine, the costs of medical care are higher and the outcomes no better.
We also know that new doctors don’t want to become primary care physicians. Those that practice primary care are getting older and rapidly retiring. In many places—including my home town in southwest Georgia--primary care practices are limiting the number of new Medicare patients they take into their practice (or not taking any new patients at all) since they can’t find more primary care doctors, nurse practitioners and physician assistants to fill the need.
In some locations, “concierge” primary care practices are becoming the next new thing, where patients pay large retainers to doctors for access to the practice. Most patients can’t afford these fees, so effectively there are fewer opportunities in some communities to get primary care unless you happen to be reasonably well-off financially.
Primary care isn’t viewed as “glamorous” by young doctors and many of my medical colleagues compared to some other specialties, and the economics of practice don’t work. Bottom line, when a young medical student looks at a future career they see that many of the considerations that influence their professional career choices—such as income and life style--weigh heavily in favor of specialty medicine as opposed to primary care.
The net result is that as our population gets older, we have fewer and fewer primary care physicians to care for them.
There are a variety of solutions that have been proposed or have moved forward to address this issue. Clinics in stores staffed by nurses is one approach. Using more nurses and physician assistants in doctors’ offices is another.
A couple of years ago, several leading medical professional societies including the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association proposed a new model of medical care delivery.
The approach would be patient centered and focused, team oriented, and provide a true holistic approach to primary care. Prevention would be a primary focus, trying to prevent illness before the ravages of obesity, hypertension, diabetes and heart disease would take hold. Care would be coordinated with specialists, and no longer would patients wonder who is in charge when they get sick. We would move to an electronic-based system, so we could monitor the health of populations of patients, as opposed to the current patchwork approach used in most primary and specialty medical care practices.
What has happened subsequently is that this model has moved from the theoretical to the development stage. The medical societies have continued to increase awareness of the concept, and gather support from numerous sources. Insurers and foundations are funding patient centered medical home demonstration projects around the country.
Congress has passed legislation directing Medicare to develop a primary care medical home demonstration project. For the past several months, I have been part of a committee that has been working with Medicare to define the medical home services, and make our best estimate of how much it will cost to provide those services. This demonstration project will likely move forward in the next several months.
Several large medical groups around the country have already implemented the medical home model, using teams of doctors, nurses, social workers and others to take care of their patients. They have installed needed technology support including advanced electronic medical records. They have regular care conferences with the medical team and families as appropriate, and carefully evaluate what they do and how they do it. They have applied the holistic principles and global approach needed to make the medical home a success.
This transformation is not going to be an easy process, and is likely going to take years if not more than a decade to accomplish. Change in well established medical care patterns are going to be difficult to alter.
That has always been the case in medicine. Change takes a long time to accomplish in my profession. But that should not deter us from our goal of making our medical care system truly a medical care system.
No one knows whether or not we are going to save money doing this. That should not be the ultimate goal, but it certainly wouldn’t hurt.
If we could coordinate medical care, make certain patients take the medicines they are prescribed, encourage patients to get preventive medical care and provide a place they can go to for not only visits but also education on how they can better care for themselves, then we would accomplish a great deal. The investment would pay for itself many times over in many ways, including economically and personally.
Ultimately, however, it’s the outcomes that count.
It has been my dream for years that we could somehow get this thing we call medical care “right”: The right care for the right person in the right place at the right time at the right cost.
It would especially rewarding in years to come if we were able to see the United States’ life expectancy move up the scale on Dr. Brawley’s slide. Maybe we might even see the cost comparison line come down a bit.
It is going to take a lot of effort on the part of a lot of people to get where we need to go when it comes to improving primary care in this country.
As a realist, I also know this is not going to be easy. As an optimist, I will bet on success.
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