Dr. A works in rural America where 50% of people are on Government insurance. She provides excellent patient-centered care: she is superbly accessible to her patients with appointments "today" to any who need them but also willing to use email, phone, and even text her patients if that meets their needs and is clinically appropriate.
Access to care is one of the pillars of comprehensive primary care:
"I can get care when and how I need it" = access to care
"I have a PCP/nurse who knows me as a person" = continuity
"My PCP meets the bulk of my health care needs" = broad array of services
"My PCP coordinates my care" = care coordination
We know from all the work of Starfield, Shi, and others that comprehensive primary care is foundation of high performing health systems. Providing comprehensive primary care is how we get to our ultimate goals of:
Improved population health outcomes
Improved experience of care
Reduced per capital health care costs
Back to Dr. A. She received a cold call yesterday from her state's Medicaid insurance plan. "Dr. A. We've noticed that your patients visit the emergency department less often than average and the difference is large. What are you doing?"
She's providing comprehensive primary care. We can do this work. We've been trained to do this work. A lot of the work of comprehensive primary care goes unpaid due to the choices made by leaders of insurance companies. It is very hard for good primary care to survive in this toxic policy environment.
Will the insurer take this improved health outcome as a windfall to the plan and continue to strangle primary care in their state with impossibly low payment rates and toxic rules, or will they step up to the plate and support comprehensive primary care?
Only time will tell.
L. Gordon Moore MD
The lack of support for comprehensive primary care has resulted in a large number of primary care physicians ending up working in hospital-sponsored clinics, as employees. As hospitals buy up primary care clinics, it is not unusual for the actual hours the clinics are open to shorten, especially on evenings and weekends.
The reason for this is quite obvious: hospitals make a very large part of their profits from their emergency rooms, and having primary care services available on the weekends and evenings takes away profits from the hospitals.
Another consequence of the lack of support for primary care is the declining number of primary care physicians who can afford to see patients with Medicare or Medicaid insurance. As fewer and fewer independent physicians are able to accept patients with these insurances, the only places where they will be able to get care is in the hospital-sponsored clinics, where the primary care physicians' salaries are backed by hospital profits, rather than by the woefully underpaid services the physicians provide to the patients.
Hospital profits are based on admissions, procedures, diagnostic tests, and surgeries. A wise and patient-centered physician who is able to take care of a patient's needs without ordering unnecessary procedures, diagnostic tests, surgeries, or admissons will really cut into a hospital's profit.
Posted by: Don Stewart | April 03, 2009 at 11:25 PM