Here is a challenge for you. Approach several of each of these categories and ask them what primary care is:
- Outpatient internists
- Inpatient internists
- Family physicians
- Nurse practitioners
- Medical subspecialists
- Surgeons
- Patients
- Health administrators
- Insurance companies
- Emergency physicians
I submit that you will hear very different answers. We put great energy into discussions of our primary care shortage, but semantics make this discussion confusing.
Read this wonderful article about Rich Baron – Delivering Better Primary Care
Rich provides high quality comprehensive care of complex patients.
Dr. Baron’s more recent paper in the health care policy journal Health Affairs describes how his practice has attempted to move away from the traditional fee-for-service care model to a more comprehensive one that is centered on the patient and preventive care. As part of a three-year statewide and multipayer-financed initiative that compensates providers for not only office visits but also prevention and disease management, Dr. Baron’s group has developed a program that encourages continuing dialogue between providers and patients with diabetes, high blood pressure and elevated cholesterol, patients who make up nearly three-quarters of the group’s practice. Patients meet with trained medical assistants and create a set of self-management goals that become part of their electronic medical record, then share the results of their efforts with the medical team on an interactive Web site and during follow-up calls.
Rich has developed a patient centered medical home. Is that primary care or that something more?
I believe that what Rich and his group do strongly resembles my recent call for Consultant Internal Medicine. What he does differs greatly from the dictionary.com definition of primary care – The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system. (American Heritage Dictionary)
We (the internal medicine community) have an obligation to better define what we do. I believe that most of my outpatient colleagues are closer to Dr. Baron's model than the American Heritage primary care definition.
But can Dr. Baron's model work given our payment model:
Q. How can we help more patient-centered and collaborative models flourish?
A. We are in a kind of Gordian knot right now. We have models for creating new devices or drugs: pharmaceutical or biotech companies create partnerships with academia. Someone says we are going to create a laboratory, shelter you, then figure out how to bring your product to the market. When devices or drugs get developed in this way, it is not under market conditions.
But we have not had the same situation in primary care. We haven’t had a protected laboratory for people to innovate around service delivery and to try to figure out how we can do better. There are huge opportunities to do our work more effectively and consistently, but we haven’t had the same kind of support.
In fact, I’m not sure we will be able to continue the new program in our practice if we cannot get resources to support us beyond the three-year commitment.
{ 4 comments… read them below or add one }
I belong to ‘Category #5′. For me, there is quite a gap between what primary care should be and what it has become. For a variety of reasons, it has become a triage machine, rather than the center of care. I wonder if my primary care colleagues agree with this assessment.
With all the discussion I read on medical blogs about the crisis in primary care, you would think that things would be heading for some sort of change but this is not the case. I spend more and more time on authorizations every year. I received a new contract from cigna last week. In addition to a clause that seems to prohibit charging an enrollment fee (something that could help primary care provide the services Dr. Baron is providing), reimbursments for medical cpts is the same as surgical and ob cpts – no increase for undervalued cognition. In addition the rates are 100% of “cigna rbrvs” with no explanation of what that means. Nothing is changing, nothing is likely to change. Those with the money, the insurers and the government seem perfectly happy the way things are. I hope Dr. Baron’s program is a success! I fear that when the special funding runs out they will need to increase the number of patient visits dramatically to pay the overhead. Just like the rest of us.
DB,
I would appreciate a further elaboration of the model you seem to be proposing. I understand your model of Consultant Internal Medicine (CIM), but if CIM is not Primary Care, what is Primary Care and who will be doing it? It sounds like you are proposing a model where primary care providers (PA’s, NP’s, FP’s) see healthy patients for physicals and common, uncomplicated acute complaints. Anyone with complex chronic diseases like COPD or diabetes would see a CIM physician. Is this an accurate description of what you forsee? If yes, then who does the primary care for a CIM patient? If a healthy patient develops a chronic disease, do they ever return to the PCP? If this is not what you mean, please explain how CIM and primary care co-exist and the value of separating the two.
I think separating CIM and primary care further decreases continuity and is a mistake. Most patients seen in adult ambulatory practices have chronic diseases, and these patients (in my experience) want the doctor who manages their chronic disease to also be their primary care provider. A better idea is a medical home model where an internist can be the PCP for all adults, using a CIM model for more complicated patients, while having some allied health professionals to assist with, but not completly take over, some primary care (pap smears, URI’s).
Though the CIM work that the adult internist already does is important, so is the primary care we do. It seems to me that separating out CIM from adult ambulatory internal medicine is an attempt to give us recognition for our expertise. However, primary care deserves recognition too. The real issue, I believe, is lack of payment for cognitive services. Redfining ambulatory internal medicine as CIM will not fix this.
It’s apparent we need more patient-centered primary care models. Like Dr. Baron, we believe that we should develop programs that encourage continuous dialogue between healthcare providers and patients. We talk about similar topics on our blog and facebook (http://www.facebook.com/healthymagination).