"The patient-centered medical home allows you to do primary care the way you would want to do it," said Graf. "From our perspective, it is really the way we do business now. It is about knowing who all of the patients in your entire populations are, where they are, what is going on with them and then being proactive about managing them."
Let me start by saying that I respect and admire Geisinger and their immense efforts to roll out quality throughout their entire organization, but I am dismayed.
I am dismayed not by what Geisinger is doing but why it is necessary to do this work and why it deserves mention not only by communication engines of the AAFP but the President of the United States. What is so special about 'knowing who all of the patients in your entire population?" This is supposed to be the case in every primary care practice and is in fact a fundamental attribute of primary care.
As I've written in the past, primary care is different from the rest of the health delivery system because:
- It is the first point of contact: yet the reality is that most Americans must wade through intolerable waits and delay due to practices policies regarding panel size and productivity, and to slog through barriers erected by public policy (our national shame of letting personal income dictate access to care).
- Has relationships over time: yet we fracture and dishonor relationship through our 'next available' scheduling protocols (another consequence of practice policies regarding panel size and productivity), and by growing practices beyond any human ability to "know all of my patients."
- We offer comprehensive services: yet our productivity/throughput standards make it nearly impossible to address the full scope of our patient's needs so we miss opportunities to address meaningful issues and/or push our patients off to specialists for care we might have delivered well if we had the time.
- We coordinate the care our patients need from the rest of the health system: but because this work generates no revenue it is pushed to the side.
Geisinger makes headlines by doing incredibly basic work but the root cause of the problems remain unaddressed. The root cause is way we pay for health care. We pay for piecework.
The more 'visits' or 'encounters' we produce, the more money we get. Because we work under strictly regulated price caps we respond (as any economist will predict) by increasing the number of visits. Increasing regulatory and policy burdens (such as endless reporting of trivia to an increasing crowd of public and private agencies demanding data) add to our cost of business. With fixed price caps we respond again (as any economist will predict) by increasing the number of visits.
Ron Paulus MD, EVP for clinical operations "pointed out that the PCMH has been in the medical literature since the 1960s, but the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."
Why might insurers be reluctant to pay?
- The US spends more per person on health care than any other developed nation in the world and has worse population health results to show for it. Let us all agree that spending even more is dead on arrival until we have exhausted our efforts to spend it more wisely.
- Shifting funds to support excellent primary care comes at the expense of hospitals and high end specialty interventions. Since hospital systems are fierce and powerful negotiators any significant shift to support primary care could launch an all out war.
- Insurers have deep investments in their own disease/case management (even though we have yet to see significant improvements despite years of these investments). Shifting these dollars to effective primary care would call into question these fiercely defended programs.
Geisinger deserves headlines not so much for doing the incredibly mundane work of "knowing your patients" - this is one of the foundational attributes of primary care. Geisinger deserves headlines because it is WILLING to do this work when the net effect reduces income to their own hospital.
Hospital systems willing to look to the future and risk the life of their own cash cow are rare. I for one applaud and encourage their efforts.
I would like to point out that "knowing all of your patients" is a fundamental attribute of practices ascribing to the Ideal Medical Practices model. By reducing their own overhead these practices have eliminated the waits and delays, gotten off the hamster wheel and spend more time working for their patients. The work is deeply rewarding to their patients, deeply satisfying to the practice, but to once more quote Paulus:
"...the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."
I'm waiting for the headline: "Insurer fully funds effective primary care and is able to reduce premiums by 25%"