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Primary care finally getting policymakers' attention

From the October ACP Observer, copyright 2006 by the American College of Physicians.

By Robert B. Doherty

It has been 10 months since ACP released its ground-breaking report on the impending collapse of primary care medicine in the U.S. Our call to action is being heard. As a result, there may soon be a dramatic turnaround of fortune for general internal medicine and other primary care physicians.

Attention from policymakers

For the first time in many years, the people who have the most influence over health care policy in the U.S.—think tanks, foundations, employers, lawmakers, reporters, medical journals, and federal agencies—are paying attention to primary care.

Over the past several months, reports on the dire circumstances of primary care medicine have appeared in such influential publications as the Wall Street Journal, Washington Post, New York Times, Annals of Internal Medicine, Lancet, and the New England Journal of Medicine. Here's what Thomas S Bodenheimer, MD, MPH, wrote in the Aug. 31, 2006 issue of the New England Journal of Medicine:

The American College of Physicians recently warned that "primary care, the backbone of the nation's health care system, is at grave risk of collapse." And indeed, primary care is facing a confluence of factors that could spell disaster. Patients are increasingly dissatisfied with their care and with the difficulty of gaining timely access to a primary care physician; many primary care physicians, in turn, are unhappy with their jobs, as they face a seemingly insurmountable task; the quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field.

Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs. The public would benefit from microsystem improvement, with fewer appointment delays, higher quality, and more meaningful interpersonal relationships. Even specialists might recognize that they would suffer if primary care deteriorates, being forced to coordinate care and confront psychosocial issues in patients with multiple acute and chronic conditions rather than focusing on diagnosing and managing specific diseases within their scope of expertise. Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.

One of the nation’s most influential private foundations, the Commonwealth Fund, is among those who has heeded Dr. Bodenheimer’s plea. In September, the Fund sponsored a “Primary Care Roundtable” to discuss the importance of primary care and how it can contribute to improved patient outcomes and reduced costs. Invited participants included congressional staff, researchers and policymakers. Among the issues examined were policies related to improving primary care supply, including reimbursement or compensation. John Tooker, FACP, ACP’s Executive Vice President and Chief Executive Officer, was among the invited presenters.

Conferences and published “calls to action” about the future of primary care do not, by themselves, translate into concrete actions to make things better. Their importance lies in marshalling the attention, commitment and intellectual contributions of top researchers and policymakers whose voices are needed to elevate the issue of primary care to the top of the nation’s health policy agenda.

Employer Advocacy On Behalf of Primary Care Medicine

Because employers pay almost half of the healthcare bills in the U.S., their engagement is critical to bringing about the policies needed to revitalize general internal and family medicine.

IBM has joined with the ACP and the American Academy of Family Physicians (AAFP) in a collaborative effort to engage employers in a discussion about applying their collective leverage to support “patient centered primary care.” On Oct. 23, the three organizations are sponsoring an invitational summit of large employers to present an agenda for specific and concrete actions that employers can take to support patient-centered primary care. In a recent article in AAFP News, Martin Sepulveda, FACP, IBM’s vice president of global well-being services and global health benefits, eloquently explains why his company is committed to working with AAFP and ACP on behalf of primary care:

“Primary care is an abandoned, neglected, incredibly important component of what we're fighting (for) in the health care marketplace," said Sepulveda. IBM has decided to try to create "a momentum for reform and transformation" at least as powerful as the momentum that has been occurring with other health care issues, such as medical errors, transparency, quality measurement, performance and waste, he said. IBM can't walk away from this "because at the end of the day it's about the people in our enterprise and their ability to be able to perform. This is a big deal for us … it's something that we're passionate about," said Sepulveda.

Federal action

Finally, the federal government is beginning to use its enormous purchasing power to support primary care. As reported in last month’s column, the Centers for Medicare and Medicaid Services has issued a proposed rule that would shift approximately $4 billion in Medicare payments toward increasing payments for office visits and other “evaluation and management services” provided principally by primary care physicians.

On the legislative front, key members of Congress have endorsed ACP’s concept of a “patient centered medical home” and are working with the College on introducing legislation to require a Medicare pilot test of this exciting new model for financing and delivering primary care services to the elderly. Rep. Nancy Johnson (R-CT), chair of the health subcommittee of the Ways and Means Committee, is among those who have endorsed the model. Under the patient-centered medical home, practices would participate in a self-assessment process that demonstrates that they are able to provide patient-centered services to patients with chronic diseases. In return, practices would be eligible for enhanced reimbursements that would provide ongoing and sustained financial support for the practice expenses and physician and non-physician staff work required to deliver such patient-centered services.

Achieving results

Some ACP members may view the increased attention to primary care, and the few modest steps that have been taken to date to improve primary care reimbursement, as being “too little, too late.” Skeptics can point to the fact that the underlying economic, practice and workforce trends continue to suggest that primary care remains a perilous career choice.

The College has a formidable task ahead of us to translate the concern about primary care into action. But change occurs not when things are going well, but when enough people become dissatisfied with the existing state of affairs. I believe that the College’s wake-up call on the collapse of primary care medicine is being heard. And by engaging the collective clout of enlightened employers, lawmakers, researchers, and think tanks, there is reason for hope that primary care will soon enter a time of resurgence and renewal.

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