JAMA Forum: A Pulse Check on Primary Care Transformation

By Dave A. Chokshi, MD MSc

Dave A. Chokshi, MD, MSc (Image: NYU Langone Medical Center)

Dave A. Chokshi, MD, MSc (Image: NYU Langone Medical Center)

Transforming primary care was encoded into the Affordable Care Act as a central part of reforming how health care is delivered. Major investments supported enhanced reimbursement for primary care, community health center expansion, and multipayer partnerships for practice transformation. Federal funding has been locally augmented by state governments, private payers, and nonprofit and philanthropic organizations—often to support adoption of the patient-centered medical home (PCMH) model of care.

By 2015, a number of these initiatives have matured enough to produce evaluable results. An Agency for Healthcare Research and Quality synthesis report of 14 grants to study primary care transformation revealed few overarching “pearls.” Instead, the success of transformation depended on context. External recognition as a PCMH-certified practice alone was seldom sufficient as a marker of meaningful transformation from the patient’s perspective.

A Growing but Murky Evidence Base

The most rigorous PCMH evaluations have yielded generally modest—and often conflicting—results. Mark Friedberg, MD, MPP, of the Rand Corporation, who has helped lead 4 of these studies, and colleagues have argued that divergent results represent differences in both practice context as well as the medical home interventions themselves. Context matters in determining an improvement trajectory—particularly if practices lack the resources or technology to fuel transformation. In this vein, Stuart Pollock, MD, of Brigham and Women’s Hospital in Boston, has written that PCMH-focused transformation has failed in part because it elevates process (such as discharge follow-up calls) above culture and mission (such as hiring the right people).

Measuring actual implementation, therefore, matters as much as the structure of the PCMH model. Taking advantage of its scale, the Veterans Health Administration (VHA) measured key outcomes against the extent of PCMH implementation for 5.6 million veterans receiving care at VHA clinics. For the top decile of clinics (compared with the bottom decile), degree of PCMH implementation was associated with better patient satisfaction, higher quality, less staff burnout, and lower acute care utilization.

Differences in the medical home interventions themselves offer the possibility of refining the structure of transformation. Friedberg highlights upfront supplemental payments for care management as well as shared savings financial incentives as 2 potential key elements of more successful PCMH interventions. The Centers for Medicare & Medicaid Services (CMS) recently announced initial results from the Comprehensive Primary Care initiative, which includes both of these structural elements.

The initiative spanned multiple payers for 483 practices serving 2.7 million patients across seven regions. While an independent evaluation remains to be published, CMS cited positive quality performance, particularly on patient experience and readmission measures. Cost results were more modest, with only 4 of 7 regions generating gross savings (excluding care management fees) and only 1 of the 7 generating net savings (and thereby earning shared savings) in the first year.

Does Any of This Matter for Patients and Clinicians?

The debate around PCMH evidence can lose sight of the ultimate goals: tangible improvement in patients’ experiences and outcomes. In the studies described above, most medical home interventions increase patient satisfaction but few show substantial improvement in health outcomes or other measures of patient-centeredness, such as whether patients are involved in the design of transformation efforts.

Teams led by Thomas Bodenheimer, MD, of University of California, San Francisco, and Arnold Milstein, MD, of Stanford University, have both conducted in-depth examinations of positive-outlier primary care practices. Both emphasize deeper patient relationships through more robust access and continuity with care teams. When access and continuity are in tension, patient preference determines which takes priority, reflecting a broader move toward shared decision making. Panel management, health coaching, integrated behavioral health, and complex care management are all considered fundamental responsibilities in primary care. For example, at the Southcentral Foundation clinics in Alaska, behavioral health consultants are considered core members of the care team. Spatial work arrangements facilitate rapid face-to-face communication among members of the team, enabling panel management and triage of complex cases.

A second type of approach toward primary care transformation involves more elemental reinvention of care models. Some organizations have attempted to reinvent scalable primary care models from the ground up, starting with how the practice is paid. At Iora Health, for example, payment is driven by a risk-adjusted fixed fee per patient for comprehensive primary care; physicians and other staff are salaried. The simplified payment model has allowed for investment in technology oriented around care instead of billing. It  also influences culture—for example, by allowing teams to meet patient needs more flexibly, such as through home visits or, in some cases, helping pay for housing.

Similarly, the practice ChenMed has also leveraged risk-adjusted Medicare Advantage capitation to innovate primary care delivery for seniors with multiple chronic conditions. Their model includes having longer and more frequent patient visits, providing free transportation to patients, and placing an emphasis on cultivating a physician culture around relationship-building and the desire to be accountable for outcomes.

Translating best practices and lessons from upstart innovations into policy is not straightforward. However, a few main considerations may help point a way forward.

First, workforce development must become front and center to address the culture change issues described herein. The CMS recently made a significant outlay for clinician engagement in the form of $685 million awarded for practice transformation learning networks. Recruiting and retaining bright younger physicians into primary care, particularly in community health centers and other safety-net clinics, is an urgent priority. And professional development must extend to all members of the care team, with particular attention to medical assistants and community health workers.

Second, new care models including virtual visits, retail clinics and urgent care centers, and technology-enabled specialist consults will force a rethinking of what constitutes primary care. Longitudinal patient relationships and a prevention-oriented mindset must remain at the core of primary care. Quality metrics, which primary care doctors generally find unsatisfactory, must be streamlined around that core.

Finally, primary care must embrace a renewed focus on caring for the highest-need patients. These include patients who are difficult to engage in care, who are “lost to follow-up,” and who have supervening social stressors. In this way, primary care transformation must keep pace with—and in many cases, lead—the transformation of the broader health system.

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About the author: Dave A. Chokshi, MD, MSc, is assistant vice president at New York City Health + Hospitals, where he leads the Office of Ambulatory Care Transformation. He is a primary care internist at Bellevue Hospital and is an assistant professor of population health and medicine at NYU Langone Medical Center. He tweets at @davechokshi. The views expressed in this JAMA Forum post are those of the author and do not necessarily reflect the policies or views of New York City Health + Hospitals. He reports no conflicts.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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