Ten Strategic Shifts for Primary Care Medicine

Across all of the health professions we face a daunting challenge: how can we change the dominant practice model to become more adaptive to the access, quality, and price demands of, patients, payers and the public, while simultaneously operating the old model at full speed in order to make ends meet? The lack of regulatory and financial incentives does not encourage the needed change. If that were not enough, there are few clinicians who are skilled in such transformations and the experience base gets thinner the smaller the organization or practice is.

The challenges exist from medicine to dentistry to optometry to nursing, but seem most acute and pressing in ambulatory primary care medicine. At a time when these practices feel themselves besieged, it is difficult to know where to begin and how to proceed with a set of changes that ask for nothing less than wholesale reform. Here are my ten suggestions of where the lever might be placed first.

  1. Move from an acute focus to a chronic orientation.
    There is certainly nothing new in this suggestion, but the current movement of primary care from its acute curative orientation to a chronic management focus is not keeping pace with the rate of the aging population. More dramatic shifts and perhaps exclusive focus on this by younger primary care physicians may be necessary if there is to be an adequate capacity to address the emergent disease burden.
  2. Understand consumer preferences and the price points for their purchases.
    Hope still springs that there will be a sweeping reform of health care and that a single payer at the state or national level will reimburse all providers for the care they feel their patients need. While such a scenario is still possible, it seems far more likely that patients will be forced to make arrangements for high deductible insurance that will protect them from financial loss associated with an expensive episode of care, but encourage them to shop around for their day in and day out care from a primary care provider. This means that to remain viable, practices must begin to understand not only what their patients need, but what they want as customers and what they are willing to pay. Some will want concierge service and no waiting, others will not mind waiting, but will expect a break in price, particularly if they can schedule in off hours. Americans have demonstrated a great capacity to pay for things they perceive have value, which is a highly dynamic combination of price and quality. Physician leaders must have a better understanding of the product and service that they are bringing forward and be willing to be a bit more entrepreneurial with it.
  3. Move the focus for delivery from the physician to the team and system.
    The foundation of medical practice is the doctor-patient relationship, but the nation can no longer afford it to be managed in 18 minute increments in the exam room. New and more effective ways to meet the needs of patients by using teams and systems must be devised.
  4. Balance point of service with range of services for self care, home-family care and community care.
    Once focus for delivery shifts from the physician to a team or system, doctors will be better able to assess when patients really need their medical expertise. Not surprisingly, this will happen less often in the exam room. As the mobility and health status of the population changes and the cost of institution-based care, even a clinic visit, grows it will provide many physicians the opportunity to move their services where they are most needed. Of course much of this expertise will be moved around in the virtual space, but one can easily imagine a patient receiving a physical at home less expensively than visiting the office, particularly if the office overhead did not exist.
  5. Transition from an exclusive focus on service to a balance of procedure and knowledge.
    As the financing of care shapes its demand and changes the location of delivery, the actual service provided by the primary care physician may more easily migrate to knowledge-based services and away from the necessity of the procedure. There is a sense among primary care physicians that they are ready for this as soon as the reimbursement switches are thrown. A counter perspective would have the provider lead in demonstrating what these arrays of services are and how they could be financed, including direct patient pay for service. It may be that the payment policy will not move until it is demonstrated in action. 
  6. Use information technology to drive population orientation. 
    There is considerable interest and investment in information technology today, particularly around the electronic patient record. However, if this record just speeds up the existing process, but does not radically break the current mode or practice, it will be a very expensive boondoggle that ultimately becomes less than it promised. The drive to e-health should lead to basic business process improvements, but these have to be done in the context of population orientation.
  7. Address generalist-specialist communication.
    The public of course assumes that generalist-specialist communication is seamless already. However, when we examine it closely there are enormous transaction costs in this relationship; Poor generalist-specialist communication can lead to monetary costs, not to mention the deterioration of patient safety and consumer satisfaction. If primary care is going to work it needs this transaction to work better than it does today. It must be timely, while affording an opportunity for the provider to play an appropriate role and return to the primary practice in an integrated manner. Each of these will require that the specialist community reconsider its relationship with primary care. The best places for this are multi-specialty group practices. If the other forms of organizing medial practice are to be sustained, this issue will have to be addressed front and center.
  8. Involve non-physician practitioners deeply in the organization and delivery of care.
    In my experience the hardest thing for a primary care doctor to give up is the contact with patients. But at some point the system must ask, and the doctors must respond to, the question: what is the objective value of this interaction to the patient? There will always be a need for patients to see the doctor, just not every time. Primary care physicians must build practices that embody their professional values and ethics and even their clinical skills in ways that do not require having them in the exam room for every encounter. This transition will be the most psychologically taxing change of all the suggestions proposed here, but it is essential if medicine is to stay in primary care.
  9. Alter the practice model in collaboration with the patient/consumer.
    Related to the last point is the need to reconsider the role of the patient in the delivery of health care in a primary care practice. For years we have been blaming the physician when patients did not do their part. It is now time for primary care to get aggressive with a kind of smart tough love for patients, breaking down some of the co-dependency that has emerged. Without honestly addressing this issue, primary care will not have a role as more and more of care and health moves out of the hospital and the clinic.
  10. Create a system of continuous innovation and improvement.
    None of these suggested actions can happen overnight. Integrating these changes will require each primary care practice to commit to a decade-long process in which small experiments are attempted, progress assessed and learning acknowledged and applied to the next small experiment set. This is of course daunting, but continuous small scale improvements have proven themselves to be what real change needs to embody to be successful.