If you look under the covers of the Group Health Cooperative 'medical home' initiative at its Factoria clinic you will find an environment that gets a lot closer to supporting great primary care:
- Panel size reduction from 2400 to 1800
- Exempt physicians from the toxic productivity pay incentives
- Add capacity to the primary care team
- Give them a little bit of coaching on 'how' and give them time to step back and look at what they're doing so they can do it better
- Group Health does not own hospitals so doesn't have to worry about that cash cow hemorrhaging over the positive effects of good primary care (fewer people landing in the ER or hospital)
It is important to keep pointing out that the probable root cause of the improvement at the practice level has to do with moving closer to an environment that supported good access, relationship, comprehensive care and care coordination. These attributes define primary care.
Group Health has had electronic records for a long time. They have been working the Chronic Care Model for a long time. These elements were in place before the Factoria medical home experiment so it may be safe to assume that these elements had little if anything to do with the before/after changes.
The likely source of the improvements in the Factoria example are similar to what we saw in the Ideal Medical Practices project: solo and small practices decompress their practices so that they can provide their patients better access, relationship, comprehensive care and care coordination. Patients in the Ideal Medical Practices project practices had results very similar to those in the Group Health project: superior experience of care, better clinical process and outcome measures, and were less likely to end up in the emergency room or hospital.
Great primary care = better access, relationship, comprehensive care and care coordination. Great primary care translates to the outcomes we want and need: improved experience of care, better clinical process and outcome measures, and reduced ER and hospital use.
We can deliver great primary care when create a supportive environment for great primary care:
- A panel size that does not exceed the capacity of the practice
- Payment policies that support the outcomes and not the billing wars
- Measurement that focuses on the right elements and doesn't get lost in peripheral detail
We can get the results we want for American health care - better population health outcomes, better experience of care, lower costs - when we have the guts to take on the sacred cows. Group Health is doing it. Ideal Medical Practices are doing it. More employers are leaving the broken system and purchasing or starting their own primary care systems, more and more physicians are leaving insurance rules behind so that they can get back to real patient care.
The status quo system is broken. All we need for real change is the will to take it on.
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