Saving primary care

One recent event that gave me a little hope for the future was the launch of a new Web site called SavingPrimaryCare.org. The site, an effort of the Ideal Medical Practices Project, is intended to help build support for a redesigned health care system in which primary care can take its rightful place. The site identifies its supporters as "a bunch of physicians, nurse practitioners, nurse midwives, physician assistants, nurses, office managers, secretaries and just plain folks who want to see the U.S. develop a high performing health system." While the effectiveness of the new site remains to be demonstrated, I find its approach encouraging. It reminds me a little of the Better Health Initiative of the Trust for Healthcare Excellence: idealistic, hopeful, representative of our better natures and, if it doesn't get chewed up in the machinery of the system, full of promise.

It was just about exactly five years ago that the Future of Family Medicine Project gave family medicine 10 to 20 years to live if  the specialty and the health care system didn't change their ways. While it hardly seems necessary to call in hospice yet, it does seem that we have been changing our ways rather slowly. The leaders of the specialty are betting that the patient-centered medical home (PCMH) is the fitness program that both the specialty and the system as a whole needs – a model for better practice that also involves a model for better payment. (Of course, it could be argued that the PCMH requires practices to transform themselves into the practices of tomorrow in order to have some chance of getting paid what they should have been paid yesterday, but that's another story.) In any case, if we are to accept the gloomy prognosis, it's clear that a lot will have to change very quickly now for the specialty to survive.

But it isn't just family medicine that's in trouble. Family physicians aren't the only ones underpaid, overworked and underappreciated. They're not the only ones practicing in a swamp of regulations, insurance hassles, 40-patient days, perverse incentives and rapacious payers. They're not the only ones operating in practices short of funds, short of management expertise, unable to measure their own effectiveness, and troubled by staffing problems. The system is hostile to all primary care, and it's all of primary care that's at risk.

That makes me wonder if one problem is that we don't have a strong enough primary-care-wide response to the problem. True, the primary care specialty societies have worked together on various issues over the years, and they're certainly together in the Patient-Centered Primary Care Collaborative – although there we find ourselves in with payers and other organizations that may have conflicting aims. Despite such examples of coordinated work, there's a sense in which the disconnection of the primary care specialties from one another, not to mention the disconnects between physician groups and organizations for nurses and midlevel providers, may weaken our response. With all the talk of team-based care these days, you'd think we'd have a team-based response to the challenges of the moment rather than the response of a loose alliance. It would be nice to think that efforts such as SavingPrimaryCare.org  could steer health care in a better direction.

Posted at 04:18PM Feb 20, 2009 by Bob Edsall  |  Comments[2]