Why is it so hard to get primary care practices to change?

There is a good deal of talk about support for primary care.  That support is demonstrated in AHRQ grants targeting interventions that support independent small and medium size practices, in a blizzard of Medical Home initiatives, and more.  There is also a good deal of concern that these initiatives may prove disappointing unless we can overcome the glacial pace of change in primary and fractional improvements observed.

What can we do to accelerate primary care transformation?  Hypotheses abound.  Some point to disappointingly incremental results of the Learning Collaborative model, others to the lack of aligned payment, still others to overly broad 'change package' that fail to promote fundamental changes. 

Many things have to go right if primary care is to make the transition. 

• We need an approach that invites the participation of all kinds of practices.  Participation costs (time away from patients, travel expense, etc) must be set very low if we are going to include the full spectrum of primary care practices including solo and rural.  The Ideal Medical Practices project demonstrated one path with group learning and practice coaching by conference calls plus online resources, all tied together with a simple measurement strategy addressing the fundamental changes required.  Group learning can break out of major urban centers and meet practices closer to home.  Regional learning can be complemented with conference call and online support.
• Assistance must address the heterogeneous nature of practices.  Coaching support, peer mentoring, and improvement pathways can be nuanced to address developmental stage, baseline capacity and infrastructure, variation in population needs.  Using a measurement system based on the fundamental features of high performing primary care can identify practices in need of further assistance.
• Launch projects in supportive environments:  Teaching transformative change without aligned payment is a waste of everybody's time.  At best we can prepare participants for a future when payment will support the work, but the full work of effective primary care is ruinous in our current payment environment.  Payment aligned with the work is necessary but not sufficient: the financial incentives must flow all the way to the front lines of work. If the aligned payment dissapears into health system general funds and has no impact on staffing and support of the work in the primary care office it is a wasted effort.
• Improve the signal to noise ratio of the measurement paradigm: Flying in the face of numerous studies we have adopted a measurement system holding primary care practices accountable for outcomes for which they are sometimes only fractionally responsible.  The primary care team is not responsible for the agriculture bill supporting terrible food choices, nor is it responsible for the epidemic of obesity and our society's willingness to restrict access to health care services based on socioeconomic status.  We play a role but often not the dominant role in a diabetic person's A1c level.  Why should we beat up practices with bad quality scores when the reason the A1c is because patients can no longer afford to take their meds because they've lost their jobs?  We can and should measure practice behaviors that predict good outcome: access, relationship over time, comprehensive services, care coordination (all easily and inexpensively measured through patient experience of care).

Primary care practices want to change.  Our professional ethics are aligned with the work of effective primary care.  Change happens when the forces are aligned with the desired results.

Comments

[Robert Watkins]

I don't know any doctor who went into family medicine expecting convenient working hours. I don't know any doctor who doesn't dream of having more time to spend with his or her patients. So I have to strongly disagree with your assertion that, if we pay family physicians better, the only change we'll see in their behaviour is that they'll go home earlier.

[Jean Antonucci]

No no -This is a wonderful post. I don't have time for this blog stuff , very much.But while it ticks me off to work for free, paying docs more ,by itslef, only lets themgo home earlier.
Getting them to change their ways takes something else and Gordon gets at it a bit here. What makes change is a resaon to do it + a reach out and touch individually approach . it is like the old joke about how many psychiatrists it takes to change a ligthbulb-- only one but the light bulb has to want to change.And it is like what it takes to work with kids. It's one on one.
And then, then you have to make change possble/accessible the one on one agian. The elements the IMP project worked for alot of people becasue they told their story and got heard and were given tools.That is slow work. thoug, if we had started a long time ago we'd be further down the road. Impersonal mass initiaves don;t work well.

[Robert Watkins]

All excellent points, but I don't think it has to be this complicated.

Family physicians are infinitely flexible and open to change: they have to be to survive in today's hostile environment. If we want different results, ALL we have to do is pay for them, and the doctors will create the necessary support systems on their own. Right now, we pay for MRIs, cardiac stents, and epidural steroid injections, and doctors figured out by themselves how to maximum their use.

Maybe the title of the post is a little misleading. How about "Why is it so hard to get health care reformers to understand that primary care physicians refuse to do any more work for free"?

Thanks.