I'm simultaneously thrilled and dismayed by the tone of an article Kathleen Patton MD (one of our IMPs in Boston MA) found on Yahoo Finance. Mr. Kurt Mosley, VP Business Development for Merritt, Hawkins & Associates (a leading physician staffing organization) is quoted:
The question "If I make this referral or order this test will it negatively impact my performance report and income?" laid its acid touch on the interactions between the PCP and patient, eroding trust and destroying relationships. Communication works better when there is trust and relationship.
Patient have identified trust and relationship as key factors that influence their probability of following preventive and chronic disease recommendations.
"I trust my PCP" results in more people begin appropriately screened for colorectal cancer, increased probability that people with diabetes will achieve adequate control of their condition and avoid unnecessary complications. Trust and relationship predict hospitalization and emergency room utilization rates - i.e. better trust & relationship, better continuity, and a person is more likely to avoid an unnecessary stay in the hospital or visit to the emergency room.
I don't know Mr. Mosley so I may be way off base in my interpretation of this quotation (please Kurt, let me know if this is the case). What may be merely a simple choice of phrase opens the door to a fundamental misunderstanding of the nature and value of primary care.
Effective primary care is not based on a gatekeeper model. It is based on achieving benchmark performance on the core functions of primary care:
Patients who receive care in practices that perform well on these metrics have better outcomes, better experience of care, and the net result of these benefits results in a dramatic drop in the total cost of health care for the population served. These outcomes are not due to care that is rationed, delayed, or denied, they are due to eliminating systemic barriers that keep people from the effective primary care they need.
When people receive care in practices that have eliminated waits and delays, eliminated inefficiencies in the office, opened portals of communication 24/7, provided great continuity & time for true interaction and communication, that go to the mat for their patients to coordinate care to make sure no ball is dropped, outcomes are better. The PCP can do right by their patient and the net effect is beneficial to all.
Anecdotes from my practice to illustrate the concept:
"I used to go to my PCP all the time and wait around. It was partly due to my frustration that he wasn't really hearing me and that way my way of getting his attention. Now that I can communicate with you any time I find myself hardly calling or coming in at all. I know you're there for me and you have the time to listen."
"Thank you so much for coming to our house to see [8 year old son] and having Judy [RN] follow up daily on the phone. You saved us another slog to the emergency department for his asthma."
These type of experiences are almost daily occurrences in practices that have fixed the access problem, have time to build relationships, offer comprehensive services, and have a financial model that supports the time and team for care coordination.
This may seem like splitting hairs but the difference is substantive hence my post. Let me reiterate:
Effective primary care is NOT: gatekeeper denial engine that keeps people from overutlization
Effective primary care IS: benchmark performance on the set of core functions noted above.
The net result of the former is distrust, fractured relationships, miserable and devalued primary care workforce and no substantive change in outcome/cost.
The net result of the latter is empowered primary care workforce, happier patients with better outcomes, reduced total cost of care.
If we really want to achieve better outcomes, better experience of care and see our health care costs come more in line with what we can afford, let's support policies and payment changes that fully fund effective primary care, that support delivery of the core functions of our work.
"The demand for primary care doctors will increase twofold when health reform happens and millions of more Americans have access to health care," said Mosley. "Who is going to triage these patients? It's not the neurologist or pulmonologist. It has to be the primary care." Kurt Mosley quoted in Money Magazine
The gatekeeper model of primary care had its heyday in the bad old days of uber-managed care. PCPs had one eye on their utilization reports and the other on the patient.
[After hearing from an associate of Mr. Mosley's I do want to acknowledge that Mr. Mosley is a strong supporter of primary care and is not proposing a gatekeeper model. I use this post to make the point @ the gatekeeper model's failings for the consideration of others.]
The question "If I make this referral or order this test will it negatively impact my performance report and income?" laid its acid touch on the interactions between the PCP and patient, eroding trust and destroying relationships. Communication works better when there is trust and relationship.
Patient have identified trust and relationship as key factors that influence their probability of following preventive and chronic disease recommendations.
"I trust my PCP" results in more people begin appropriately screened for colorectal cancer, increased probability that people with diabetes will achieve adequate control of their condition and avoid unnecessary complications. Trust and relationship predict hospitalization and emergency room utilization rates - i.e. better trust & relationship, better continuity, and a person is more likely to avoid an unnecessary stay in the hospital or visit to the emergency room.
I don't know Mr. Mosley so I may be way off base in my interpretation of this quotation (please Kurt, let me know if this is the case). What may be merely a simple choice of phrase opens the door to a fundamental misunderstanding of the nature and value of primary care.
Effective primary care is not based on a gatekeeper model. It is based on achieving benchmark performance on the core functions of primary care:
- Access
- Relationship
- Comprehensiveness
- Coordination
Patients who receive care in practices that perform well on these metrics have better outcomes, better experience of care, and the net result of these benefits results in a dramatic drop in the total cost of health care for the population served. These outcomes are not due to care that is rationed, delayed, or denied, they are due to eliminating systemic barriers that keep people from the effective primary care they need.
When people receive care in practices that have eliminated waits and delays, eliminated inefficiencies in the office, opened portals of communication 24/7, provided great continuity & time for true interaction and communication, that go to the mat for their patients to coordinate care to make sure no ball is dropped, outcomes are better. The PCP can do right by their patient and the net effect is beneficial to all.
Anecdotes from my practice to illustrate the concept:
"I used to go to my PCP all the time and wait around. It was partly due to my frustration that he wasn't really hearing me and that way my way of getting his attention. Now that I can communicate with you any time I find myself hardly calling or coming in at all. I know you're there for me and you have the time to listen."
"Thank you so much for coming to our house to see [8 year old son] and having Judy [RN] follow up daily on the phone. You saved us another slog to the emergency department for his asthma."
These type of experiences are almost daily occurrences in practices that have fixed the access problem, have time to build relationships, offer comprehensive services, and have a financial model that supports the time and team for care coordination.
This may seem like splitting hairs but the difference is substantive hence my post. Let me reiterate:
Effective primary care is NOT: gatekeeper denial engine that keeps people from overutlization
Effective primary care IS: benchmark performance on the set of core functions noted above.
The net result of the former is distrust, fractured relationships, miserable and devalued primary care workforce and no substantive change in outcome/cost.
The net result of the latter is empowered primary care workforce, happier patients with better outcomes, reduced total cost of care.
If we really want to achieve better outcomes, better experience of care and see our health care costs come more in line with what we can afford, let's support policies and payment changes that fully fund effective primary care, that support delivery of the core functions of our work.
Thank you Mr Miller! Family practice is caught in the crossroads of a health care non system full of errors , poor outcomes ,and high prices, after decades of systematic destruction of primary c are.
I can't afford to buy the book.
Thanks for letting me know it is out there
-Jean in rural poor Maine.
Posted by: Jean Antonucci | March 17, 2010 at 06:53 AM
Mr. Miller,
Good to hear from you. I too ordered your very timely book.
I hope you will come to Denver next Fall for the AAFP scientific meeting and the IMP meeting following (Oct 2-3). I'm sure Merritt Hawkins will have a presence at AAFP. Perhaps you could join us in conversation.
Posted by: Kathleen Patton | March 16, 2010 at 08:37 PM
Thank you so much for your reply. So my blog post is not at all about Mr Mosley's intent but what I have heard others propose to bring health costs in line - the re-invigoration of the gatekeeper model.
I'm ordering the book.
Thanks for your support!
Gordon
Posted by: Gordon Moore | March 15, 2010 at 06:05 PM
Greetings. I work with Mr. Mosley, who is out of the office today making a presentation before the Maryland Hospital Association entitled "Who Will Save Primary Care?" I know he would agree that primary care doctors can and should be more than triage agents. Our company (Merritt Hawkins) has helped put together a new book on the current untenable position many primary care physicians find themselves in. It's called "In Their Own Words: 12,000 Physicians Reveal What They Really Think About Medical Practice in America" (available on Amazon.com). Please let me know if you would like further information.
Posted by: philip miller | March 15, 2010 at 10:14 AM